Ceramic Veneers Contact Lenses and Fragments

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PAULACARDOSO & RAFAELDECURCIO
Florianópolis/SC - Brazil
2018 - 1st edition
TITLE
Ceramic VENEERS: contact lenses and fragments
1st Edition, 2018

Editora Ponto Ltda.
ISBN: 978-85-60023-19-6
AUTHORS
Paula de Carvalho Cardoso & Rafael Decurcio
GRAPHIC DESIGNER
Emmanuel Fontes
PORTUGUESE REVIEWER
Giovanni Secco
ENGLISH VERSION
Fabio Luiz Andretti, DDS, MSD, PhD
Paul Anthony Luz, PENR
This book is a publication of Ponto Publishing Ltd., Avenida Othon Gama D’Eça, 900, Sala
810, Centro, Florianópolis, Santa Catarina, Brazil, CEP 88015-240.
No part of this publication may be reproduced without prior permission from the Editor.
INFORMATION:
editoraponto@editoraponto.com.br
www.editoraponto.com.br
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@EditoraPonto
(55 48) 3223 9150
Cardoso, Paula
Ceramic venners : contact lenses and fragments / Paula Cardoso & Rafael
Decurcio ; [English version Fabio Andretti, Paul Anthony Luz]. -- 1. ed. -- Florianópolis,
SC : Editora Ponto, 2018.
Título original: Facetas : lentes de contato e fragmentos cerâmicos.

ISBN 978-85-60023-19-6
1. Odontologia 2. Cerâmicas dentárias 3. Facetas dentárias 4. Lentes de contato I.

Decurcio, Rafael. II. Título.
18-16899 CDD-617.692
Cibele Maria Dias - Bibliotecária - CRB-8/9427
authors
PAULA DE CARVALHO CARDOSO
MS, PhD in Restorative Dentistry / UFSC
Specialist in Restorative Dentistry / HRAC-USP
Professor, Specialization Course in Restorative Dentistry/ ABO-
GO
Coordinator of the Course “Ceramic Veneers –
Building a Predictable Protocol”/ ABO-GO
RAFAEL DE ALMEIDA DECURCIO

MS Oral Rehabilitation / UFU
Specialist in Periodontics / ABO-GO
Professor, Specialization Course in Restorative Dentistry/ ABO-GO
Professor of the Course “Ceramic Veneers –
Building a Predictable Protocol”/ ABO-GO
LÚCIO JOSÉ ELIAS MONTEIRO
MS, Restorative Dentistry / SLM-Campinas-SP
Professor of the Course “Ceramic Veneers Building a Predictable Protocol”/ ABO-GO
MARCUS VINÍCIUS N. M. DOS R. PERILLO DE FREITAS

Specialist in Restorative Dentistry / ABO-GO
TERENCE ROMANO TEIXEIRA

Specialist in Restorative Dentistry/ ABO-GO
Specialist in Periodontics / Uberlândia
Specialist in Implant Dentistry / Uberlândia
WILMAR PORFÍRIO DE OLIVEIRA

CDT, Owner Wilmar Porfírio Dental Laboratory
ANA PAULA RODRIGUES DE MAGALHÃES

MS, Dental Clinics / School of Dentistry / UFG
Associate Professor of the Department of Restorative Dentistry / UNIP-GO
Professor of the Course “Ceramic Veneers – Building a Predictable Protocol”/ ABO-GO
coauthors
PEDRO LUÍS ALVES DE LIMA
Assistant Professor, Specialization Course in Restorative Dentistry/ ABO-GO
Assistant Professor of the Course “Ceramic Veneers – Building a Predictable Protocol”/ ABO-GO
AMIN DE MACEDO MAMEDE SULAIMEN

Assistant Professor of the Group ImplantePerio / ABO-GO
Specialist in Periodontology and Implant Dentistry / ABO -GO
MSD Implant Dentistry / SLMandic
JOÃO CHRISTOVÃO PALMIERI FILHO

Master in Prosthodontics / UnB
Specialist Implant Dentistry / ABO-DF
Specialist in Occlusal Diagnostics and Rehabilitation / DATO Dental Practice -
Buenos Aires
GUIDO CIRILO FERREIRA

Assistant Professor, Specialization Course in Restorative Dentistry/ ABO-GO
Assistant Professor of the Course “Ceramic Veneers – Building a Predictable Protocol”/ ABO-GO
ALTAMIRO FLÁVIO RIBEIRO PACHECO

Specialist Prosthodontics / UFU
Accredited member of the Brazilian Society of Aesthetic Dentistry (SBOE)
ANDREA MELO
PhD Student Restorative Dentistry / UERJ
MSD Materials Science / IME
Specialist Prosthodontics / UVA
Graduate in Periodontics / OCEX
JÚNIO S. ALMEIDA E SILVA

Specialist in Restorative Dentistry / UFSC
Visiting Researcher, Department of Prosthodontics /
Ludwig-Maximilians Universität, Munchen, Germany
FERNANDA G. V. PALHARES SAKEMI

Specialist in Restorative Dentistry
Professor, Specialization Course Restorative
Dentistry / ABO-Uberlândia-MG
JULIANA NUNES ROLLA

MS, Restorative Dentistry / PUC-RS
Associate Professor, Restorative Dentistry / UFRGS
Professor Specialization Course, Restorative Dentistry / UFRGS
JULIANA ROMANELLI
Specialist in Orthodontics and Dentofacial Orthopedics /
UNICASTELO
MSD Oral and Maxillofacial Prosthodontics/ FO-USP
Assistant Professor, Courses of Excellence in Periodontology
and Implant Dentistry / ImplantePerio Institute
CRISTIANO SOARES
CDT / Integração-Campinas-SP
Shareholder and Owner of the Laboratory “J. Soares”, Head of the sector of
customized dental works / Campinas-SP
Ceramist, Private Practice, Prof. Dr. Eric Van Dooren / Antwerp-Belgium
Coauthor of the book “The Pursuit of Aesthetic Excellence”, Editora Napoleão
Coauthor, QDT Year Book 2014 and 2015, Quintessence
coauthors
LUCIANO REIS GONÇALVES
Specialist in Periodontics / USP-Bauru
Specialist in Implant Dentistry / UNESP-Araçatuba
Specialist in Prosthodontics/ Funorte-Goiânia
VICTOR CLAVIJO
PhD, Restorative Dentistry / UNESP-Araraquara
MSD, Restorative Dentistry / UNESP-Araraquara
Specialist Restorative Dentistry / UNESP-Araraquara
Specialist in Implant Dentistry / SENAC-SP
RENATA GONDO MACHADO

PhD, Restorative Dentistry / UFSC
Specialist, MSD, Restorative Dentistry / UFSC
Associate Professor Restorative Dentistry / UFSC
MAX SCHMELING
PhD, Restorative Dentistry / UFSC
MSD, Restorative Dentistry / UFSC
Peer-reviewer, Restorative Dentistry,
Journal of Dentistry and
Odontology - Japan
JUSSARA BERNARDON
Professor Graduate Program - MSD and PhD / UFS
LEANDRO DE CARVALHO CARDOSO

PHD, OBMFS / UNESP-Araçatuba
Master in OBMFS/ UNESP-Araçatuba
Specialist in CTBMF / CFO
Specialist in Implant Dentistry / APCD-Araçatuba
preface
Brazil is not “great” because of its immense territory, but because of its people (al-
though many would have us believe the opposite). Rafael, Paula and the entire staff of this
wonderful book inwhich I have the honor to introduce, are an undeniable proof of what I
believe in and for many years what I have been saying. People are the greatest wealth of
any country, and this is no different in Brazil. I met Paula, more than 10 years ago, during
a dental event, while she was still an undergraduate student in the city of Anápolis, Goiás,
Brazil. Afterwhich I had the privilege of being her professor during her masters and doc-
torate courses at the Federal University of Santa Catarina in Florianopolis, where I teach.
In contrast, I met and became Rafael’s friend not long ago. Yet, deep down, I have the
impression that I have always known him, such is our affinity and mutual respect. I have
had the pleasure and the joy of working with them both in the specialization courses in
Dentistry and in some of our short-duration courses on ceramic veneers at ABO Goiás.
They are one more proof that dreaming is an universal right and that our dreams do not
get fulfilled on their own. They only manifest true through hard, persistent and patient work.
The work is what carries out the dreams. To accomplish another one of his dreams, that
is, this wonderful book, Paula, Rafael and the entire group who work with them are being
reaffirmed more and more, a great example to thousands of young people who want to
build, as they have, a beautiful career. This book, in addition to its up-to-date content,
is easy to understand and scientifically supported, and overwhelmingly illustrated with
immaculate photographs. Countless case reports optimally documented reveal the exten-
sive experience of the authors and co-authors in this particular field of Dentistry. Indeed,
a wonderful book. If you have any questions, I suggest that you carefully go over each
page and then proceed reading without any hurry. I am sure you will agree with me and will
also be proud of what they were able to produce, at such a young age. Congratulations,
my friends. I am so proud of you all.
Luiz Narciso Baratieri

acknowledgements
Despite being the first to be read in books, acknowledgements are usually the last to be written. Authors
focus their energies on objective, scientific and technical issues, and at times fail to conclude their work with
the proper acknowledgments. With the hope of not committing the offense of forgetting anyone, and as well not
categorize people in order of importance or interest, we would like to express our sincere gratitude to everyone
who participated in this literary project, from its very conception through to its editing. We would also like to ack-
nowledge the attributes, and not solely the characters.
First (even being impossible to attribute Him adjectives) we thank GOD!
CONFIDENCE. To all of the patients presented here and to everyone else that had offered us their confiden-
ce and their hope for change. Since the introduction of the clinical course entitled “Ceramic Veneers - Building
a Predictable Protocol”, a paramount importance has been given to the patient who can successfully make our
innovative and unique dream come true.
ALTRUISM. A term more than synonymous of those individuals like Tereza, Cleide, Wauner, Denise, Henri-
que, Thiago, Maria, Jacyra, Ângela and many others. Thanks to ALL of the employees who selflessly supported
the work undertaken by the Restorative Dentistry Team from ABO-GO over the years
LOYALTY. Cleide Rocha and Katarina de Souza exemplify the embodiment of this concept. There is no
day, time, difficulty, workload or mood ... their loyalty transcends rational issues. With them “a mission given is a
mission accomplished”.
WILLINGNESS. Without hesitation, we received a “yes” from all of our co-authors which costed them seve-
ral hours a year from their families, friends and leisure time, in order for them to engage in the full cooperation of
the completion of this project.
MAGIC. Fontes materialized into pages what we only could have ideally dreamed of.
COMPLICITY. Summing up heterogeneous characteristics, our team unites itself in complicity with the total
absence of personal vanity and an unmatched desire to see that each and every task is “well done”. Lúcio Mon-
teiro, Altamiro Flávio, Marcus Vinícius Perillo, Terence Romano, Maria Geovânia, Ana Paula Magalhães, Guido
Ferreira, Pedro Lima, Amin Mamede and Alfeu Neto form the group of authors and testimonies of this book.
FRIENDSHIP. With a relationship initiated for the pursuit of knowledge, our students and alumni have be-
come great friends, each of which has contributed to the growth of the teaching-learning experience and have
actively participated in the construction of the clinical cases as well as in the life-time transformation of innume-
rous patients.
EXCELLENCE. Since Dentistry is predominantly technical, where obedience to a protocol and the repetition
of steps are what lead to the anticipated results, José Carlos Romanini, Murilo Calgaro, Leonardo Bocabella and
Cristiano Soares are outlying individuals which have gifted this book with amazing cases, incorporating inspiration
and naturalness to such a technical field of Dentistry.
PARTNERSHIP. Of those few that life seldomly offers. DUDU MEDEIROS became a partner and friend, left
responsible for much of what has been carried out by our team in recent years. In this book, far more than photo-
graphing most of our patients, he gave us his expertise and an eye for beauty that escapes ones common sense.
Paula Cardoso & Rafael Decurcio

special acknowledgements
We dedicate a special chapter to Wilmar Porfirio.
Much more than a service provider, leading a team of over 40 employees, Wilmar
Porfírio, turned into a great partner and friend, who became largely responsible for carrying
out this book.
Simple, humble and “hill-billy” born, as he likes to call himself, Wilmar is a genius in
service to the field of Cosmetic Dentistry. By quirk of fate or unexplainable convenience,
he (we fear that ever) will still be recognized by technically idealizing the ceramic injection
technique for fabrication dental contact lenses. But it does not matter! Devoid of personal
vanity and excessive ambition, the genius is content to be satisfied with the results of the
work of his team jointly, the smiles captured by comparative “before and after” pictures
and kind emails of thanks.
Yes... he is like that!
He is an unconditional supporter of our ideas and projects, and as a professor of our
courses, he works with the simplicity of his personality and with a non-academic lecturing
skill based on the brilliance of what he does and who he is!
Wilmar Porfírio, we extend our most sincere gratitude to you for carrying out most of
the cases presented here, for teaching openly your technique, and for the opportunity of
living with your elevated spirituality through your simple way of seeing and living life!

dedication
“I dedicate this book to my parents Paulo and Lucienne, who taught me to dream and gave me all the
support for my personal and professional growth; to my brothers Paulene and Leandro, who always walk next
to me; to my grandmothers, for sharing their experience; my sons Leonardo and Bruno, who make me strong
and stimulate my betterment each and every day; and to my love, Rafael Decurcio, for holding my hand in
such a sublime way without giving up and with the certainty that happiness is reachable!”
PAULA DE CARVALHO CARDOSO
“I dedicate this book to my little princesses, Rafaela and Giovana, that one day will understand the real
importance of work and dedication as a means to happiness; to my brothers, Paulo and Daniel, who never
refused their implicit or explicit support; to my mate and accomplice, Paula Cardoso, who taught me what
only hearts know; and, in a special way, to my parents, Paulo and Wilma, for their example of uprightness of
character, for the unconditional demand placed upon my studies and further for their own dedication to work
and for the greatest love I’ve ever felt in the world.”
RAFAEL DECURCIO
eternally grateful
By far, this is the most difficult text to be written throughout the course of the produc-
tion of this book. All of the months of hard work and dedication, the numerous literature
searches, the hundreds and hundreds of hours of photographic documentation of the
whole process of work are not as difficult as to express in written words your importance
in our lives.
Professor, Master Supervisor, Coordinator, Head, Owner, Reference, Friend,
Companion, or anything else that fits, Baratieri is our everything! Directly and absolutely
responsible for everything that we have achieved professionally and personally, since his
presence in our lives.
With a strong focus and a sharp sincerity, he is able to command with the stren-
gth of a father and the love of a mother. Incomprehensible decisions in the present are
reflected into lucid solutions of tomorrow with that rare insight of the few. With frightening
childlike energy, he urges all those that surround him always forcing us to walk with no
thought of regret. We are sure that if we could bottle this elixir, we would be millionaires.
But we do not! Neither us, nor anyone acting in Aesthetic Dentistry. We are alre-
ady billionaires for the unique opportunity to be around him and take advantage of all the
treasure he produced, produces and will produce for the common good.
Baratieri.... to you forever grateful, we offer our canine faithfulness and our Spar-
tan loyalty!
WS Team forever!

summary
SECTION I. INITIAL
CHAPTER 1. A NEW AGE IN DENTISTRY 26
CHAPTER 2. AESTHETIC PRINCIPLES 30
CHAPTER 3. SHADE SELECTION AND
REPRODUCTION IN CERAMIC VENEERS 70
CHAPTER 4. AESTHETIC REHABILITATION PLANNING 90
SECTION II. BEFORE
CHAPTER 5. OPTIMIZATION OF THE
AESTHETIC AND FUNCTIONAL RESULTS 124
CHAPTER 5.1. THE RELEVANCE OF ORTHODONTICS AS AN INITIAL
THERAPY BEFORE RESTORING WITH CERAMIC VENEERS 126
CHAPTER 5.2. PERIODONTAL PLASTIC SURGERY 146
CHAPTER 5.3. DENTAL BLEACHING 178
CHAPTER 5.4. OCCLUSAL PLASTIC RESTORATIVE THERAPY 194
SECTION III. IMPLEMENTATION

CHAPTER 6. ON SIZE OF THE RESTORATIONS 226
CHAPTER 6.1. PREPS FOR CERAMIC VENEERS 228
CHAPTER 6.2. CERAMIC FRAGMENTS 268
CHAPTER 7. CERAMIC SYSTEMS 296
CHAPTER 8. IMPRESSION TAKING FOR CERAMIC VENEERS -
THE ESSENCE OF COMMUNICATION 316
CHAPTER 9. TEMPORARY RESTORATIONS FOR CERAMIC VENEERS 338
SECTION IV. CEMENTATION

CHAPTER 10. DENTAL ADHESION 356
CHAPTER 11. RESIN CEMENTS 372
CHAPTER 12. LUTING PROCEDURES 388
SECTION V. FOLLOW-UP
CHAPTER 13. MAINTENANCE 418
CHAPTER 14. FAILURES OF CERAMIC VENEERS 432
CHAPTER 15. BEFORE AND AFTER 468
SECTION I. INITIAL
A NEW AGE IN DENTISTRY
CHAPTER 1
a new age in dentistry
Paula de Carvalho Cardoso | Rafael Decurcio
Ceramics, resin cements, rehabilitation treatment planning, tooth morphology, aes-
thetic parameters, adhesion - whatever it may be the subject of contemporary dentistry
to be presented, they are always to be preceded by a deep-rooted concept in humanity:
Beauty!
Both the operatory techniques and the physical and optical behavior of the mate-
rials have been widely studied in Dentistry throughout its history. However, how does one
conceptualize Beauty objectively? How do we come to understand such an extensively
conceptualized concept, which was revised throughout the entire history of mankind, whi-
ch is neither tangible, nor generates unanimity, as well as people?
The diversity of the beauty concept in constant change comes from the Pre-socra-
tic era of philosophy, which lends strong mathematical association of beauty to shapes
and accurate measurements. The European Renaissance, between the fourteenth and
seventeenth centuries, rediscovered the concept of classical beauty, one in contrast to
the Gothic Era, which conceptualized that non divine beauty was sinful and should be vis-
cerally rejected. Later, Humanism revisited the concept of Beauty which once again came
down to mathematical harmony and rational analytical order. Already in the Post-Modernist
phase, beauty was once again philosophically rejected, appearing as an unsightly portrait
in its artistic forms of expression. And today? How should we conceptualize Beauty? And
what is the real significance of such great historical concepts and philosophical diversity in
relation to such a thrilling and alluring theme? Perhaps no importance at all or it may be that
they are fully important, depending upon ones point of view. If we imagine that we should
guide our choices and decisions on current concepts, the historical philosophical chan-
ges are harmless. However, if we think that the concept of beauty is changing and that our
choices today can reflect an unbearably ugly and unpleasant tomorrow, the History of Phi-
losophy will at least help us by providing us with parsimony and wisdom to decide and act.
In the beginning of this century, especially over the last eight years, Dentistry was
greatly influenced by an incessant social quest for aesthetic perfection, creating a new and
dangerous era: “The Age of Veneered Patients”. People have been treated in a standardi-
zed and digitized manner, by producing identical results for different people. Age, gender
and physical characteristics have been excluded from the evaluation process in the pur-
suit for ease of treatment delivery to achieve this so called dreamed Aesthetic Perfection.
But will the dreamed Aesthetic Perfection override the individuali?
28
Even facing all of the conceptual and philosophical changes to Beauty, we must
react and reflect on the etymological concept of the word. In Greek, Beauty, or Beautiful,
is defined as “time” and it is associated with a particular time. It can guide not only dental
practice but also our vision of the world: it make us to come to understand the beauty
of the buildings at the very time they were errected, the beauty of a small country village
quitely opposed to our urban life, to the timeless beauty of the classical arts, the beauty of
a smile in its respective age that possesses it, as well as the beauty of the white and the
yellow. Etymologically, Beautiful is related to a time, it is all about the moment, the age, and
gender. Beauty then, is individuality at that very moment in time.
The aim of this book was to introduce a philosophical work based on established
clinical protocols supported by literature on ceramic veneers, specifically on how to cus-
tomize the treatment planning and to further implement aesthetically, functional rehabilita-
tions without extending beyond its precise indication, blending patient’s expectation and
professional’s decency and ethics.
29
chapter 2
aesthetic principles
Paula de Carvalho Cardoso | Rafael Decurcio | Altamiro Flávio Pacheco
Ana Paula Rodrigues de Magalhães | Marcus Vinícius Perillo
Promoting health and respecting the biology of the individual, have always been
principles of treatments proposed in Dentistry, with the aim of conveying physical care and
achieving highly physiological results. Following evolution and technological advances,
Dentistry has come to address psychological aspects through aesthetic rehabilitations, ie,
the ability to restore the physiological shape of a smile, respecting the patients’ biology,
highlighting their positive aesthetic features, while adapting to their lifestyle, job and social
status.13 Noting both of these aspects, it is imperative to settle which aesthetic standards
one should be based, first of all upon factors related to health of the individual. Thus, the
correct rehabilitation planning becomes essential.
Given the importance of a smile and the complexity of its evaluation, a number of
parameters such as facial, dentolabial, gingival as well as dental references are extremely
important in identifying and recording all data needed to optimize the aesthetic appearan-
ce of the prosthetic rehabilitation.21,54
Thus, while focusing on the harmony between the face and hard and soft tissue
components of the oral cavity,21 a method to display each case becomes mandatory. The
patient-tailored analysis based on optimal aesthetic references, that seeks to achieve ob-
jective parameters for the implementation of aesthetic treatments, provides an opportunity
for universalization of expertise to the most difficult task of Aesthetic Dentistry, treatment
planning.
FACIAL REFERENCE LINES

Fradeani22 described the topics of facial analysis that should be addressed for each
FACIAL ANALYSIS
individual patient in cases of oral rehabilitation. According to the author, horizontal referen-
ce lines, vertical reference lines and facial proportions must be taken into consideration as
a starting point in the aesthetic planning.
Extraoral photos are used at the moment of the facial analysis and proper patient posi-
tioning is essential for carrying out the digital planning (see Chapter 4).22
Within these parameters, the main horizontal and vertical lines are: (Figure 1b)
1. the interpupillary horizontal line (passes through both pupils);
2. the horizontal line of the labial commissure (passes through the labial commissu-
res);
3. the horizontal eyebrow line (passes through both eyebrows);
4. the vertical midline (center of the upper lip);
5. vertical lines of the nostrils (line tangent to the nasal alae); and
6. the horizontal line of the incisal edge.
Horizontal reference lines are used to analyze the parallelism between the structures.
The literature is unanimous on the importance of parallelism between horizontal lines of
the face, such as the interpupillary, the eyebrow and the labial commissure lines.14,62 Often
these references are used to guide the incisal plane, the occlusal plane and the gingival
contour.22
32
There is a statistically significant correlation between the interpupillary line and the incisal edge of the maxillary central
incisors, regardless of gender.1 A study by Malafaia et al.45 reports that 70.59% of the studied population showed paral-
lelism between the described lines.
In situations where the interpupillary line and the commissure line are parallel, but diverge from the horizontal plane,
they could still be used as a prosthetic rehabilitation guide.22
The facial midline is determined by the following points of reference: glabela, the tip of the nose and the tip of the
chin. (Figure 2). The middle line is perpendicular to the interpupillary line and forms a “T”.48 This intersection of the midline
Figure 1b.
Figure 2a.
Figure 1a. Figure 2b.
Figure 1. Frontal photo of the smiling patient (a) and the same photograph with the tracings of the horizontal and vertical lines (b).
Figure 2. Frontal photo of the smiling patient with the marking of points (a) to guide the demarcation of the facial midline (b): glabela, tip of the nose and chin.
Photographs by Dudu Medeiros.
33
with the aforementioned horizontal planes creates a type of organized structure in which it
is possible to identify the presence or the absence of symmetry between the right and left
sides of the face. The facial asymmetry tolerated between the right side and the left side is
3%; more than that the asymmetry is evident and aesthetically unpleasant.22
According to Kokich,36 from the prosthetic standpoint, the lack of alignment betwe-
en the glabella, the nose tip, and the tip of the chin hinders the identification of the facial
midline. In these situations, the center of the upper lip, or the lip filtrum should be used as
the reference.28 (Figure 3)
The optimal average dental lines (upper and lower) should be coincident each other
and along the facial midline. However, Miller, Bodden and Jamison47 found that 70.4% of
the studied sample showed coincidence of the dental midline with the facial midline. A
Figure 3a. Figure 3b. Figure 3c.
Figure 3d. Figure 3e.
Figure 3. Patient Frontal photo (a-b) where there is no alignment of forming points of the midline, complicating its tracing (c). It was then traced following the philtrum (d). This patient also features
titling of the bipupilar line. Photos after the rehabilitation of the patient, with the philtrum as reference of the midline, showing dentolabial and dentofacial harmony (e) although keeping discreet bilateral
discrepancy of the upper lip volume while smiling.
34
slight misalignment between the upper and lower midlines is rarely perceived, especially
by lay evaluators, who do not visualize up to 3 mm deviation;17,58,62 therefore, it does
not represent an obstacle in obtaining optimal aesthetics. Nevertheless, some patients
request a perfect coincidence between the interincisal midlines. Under these requests,
clinicians and technicians attempt to realign the maxillary and the mandibular arches using
the inclination of the dental axes which may cause an unpleasant aesthetic appearance.37
Clinically, in cases where there is pronounced deviation between the maxillary and
the mandibular midlines which is not to be corrected prior through orthodontics, a man-
ner to to achieve smoother and more pleasing results, even with the given limitations, by
carrying out the rehabilitation with the proximal surfaces of the involved teeth as parallel as
possible. (Figure 4)
Figure 4c.
Figure 3. Frontal photograph of the patient that presents deviation from the dental midline as to midline of the face (a) and close-up shot of the smile (b). Photography conventional preparations for
ceramic veneer veneers carried out with greater reduction on the mesial surfaces of the teeth on the right side (c). In the final shots of the rehabilitation, the proximal surfaces were made parallel to each
other(d), providing a satisfactory result, in that the deviation has not been fully corrected, but was softened by configuring the tooth shape (e).
35
The nostril lines are two imaginary vertical lines that are bilaterally tangent to the nose wing, which determines the
interalar distance with the patient smiling. These lines can help in two aspects: (1) to analyze the symmetry of the nose with
the face; and (2) help at assessing the optimal size of the six anterior superior teeth. (Figure 5)
The nasal alae line determines the harmony of the nose with the face, something fundamental when planning, after all
one can not have doubts about the patient’s complaint, as the disharmony often lies in the width of the nose, and not the
dental condition.51 Thus, the nasal alae line determines if the nose is symmetrical, wide or narrow for the face.39,40
According to Gomes et al.,25 the ideal average interalar width during a smile is 38.7 mm for females and 43.1 mm for
males. Another detail that brings harmony to the face is the nasal alae is that the line vertical tangent to the medial border of
the sclera (“white of the eye”); conversely, the greater the distance of the nasal alae from the sclera, the most asymmetrical
(wider or shorter) the harmony.
Another important condition is that line of the nose wing should be tangent to the distal portion of the maxillary canines,
which shows an optimal ratio for the width of the six anterior superior teeth during the smile,60 confirming the relationship
between the structures described in the work of Gomes et al.25 This reference line, while providing data for the analysis of
the nose symmetry in relation to the face and establishing the width of the six anterior teeth, helps in determining the distal
or mesial positioning of the maxillary canines whether by tooth movement, either by the gaining of the labial volume of the
anterior teeth in cases of lingual positioning of the crown.
The line of the incisal edge, where the smile line or
the incisal curvature is determined by an imaginary line that
touches the incisal edges of the anterior superior teeth.
This greatly influences the smile aesthetics.
Ideally, the incisal edge is convex and should be
parallel to the upper edge of the lower lip, which promo-
tes radial symmetry or the incisal curve. This is present in
84.8% of cases.23,68,31 (Figure 6) However, the curvature of
the lower lip is not always homogeneous and can present
variations between both sides of the face including hype-
ractivity during smiling and with aging. Thus, it should be
based on the horizontal reference because it is a fixed pa-
rameter and a static reference for leveling the incisal edges
of the anterior superior teeth.62 (Figure 7)
The lack of parallelism between the incisal plane and
the curvature of the lower lip typically is due to a flatening
of the incisal line or even inversion of the incisal edges,
creating a negative anterior space and a significant smile
artificial.2 Horizontal asymmetry occurs due to either functio-
nal or parafunctional wear or skeletal changes or both, and
causes four aesthetic impairments : (1) the incisal edge of
Figure 5.
Figure 5. Frontal photograph of the smiling patient with the tracing of nose wing lines allowing
for the evaluation of the nasal symmetry with face, touching the medial border of the sclera; and
the relationship to the dimension of the six anterior superior teeth touching the distal portion of
the upper canines.
Photograph by Dudu Medeiros.
36
Figure 6c. Figure 6d.
Figure 6. Frontal smile photography of a patient with tracing representing its incisal edge (red) and the outline of the lower lip (yellow) (a). The incisal edge is concave and does not match the lip contour.
With the lips retracted and the teeth on a dark background, this concave shape is even more evident (b). After the aesthetic rehabilitation of the patient, was obtained the radial symmetry with the
coincidence of these two lines in smile and harmony of the incisal curve (c-d).
Figure 7. Frontal photography of the smile of a patient with lower lip asymmetry, resulting in a heterogeneous curvature of the lip (a-b). The rehabilitation was based on the horizontal, eyebrow, bipupilar
and commissure reference lines (c), and not in the curvature of the lip, when building the incisal edge, obtaining the harmony with the face (d-e).
37
Figure 8a-b. Patient presenting parafunctional wear and subsequent flatening of the smile line.
the anterior superior teeth is not parallel to the curvature of the upper rim of the lower lip; (2)
decreased display of the central incisor at rest; (3) reduction of interincisal angles (the incisal
embrasure); and (4) an evidenced anterior negative space.27 (Figure 8)
In addition to these highlights, there is a clear change within the height/width ratio
of the clinical crown and loss of the opaque or opalescent halo in the case of attrition.
The final sum of all aspects analyzed above is the determination of a smile with an elderly
appearance.
The shape of the incisal edges is a fundamental parameter. In middle-aged and
elderly patients, the incisal edge shape is often a straight line or an inverted curve, which
creates uniformity and an artificial leveling of the smile line. In this situation, the incisal
embrasures are small or absent, which makes the incisal edge flat and contributes signifi-
cantly to an unpleasant effect and an inevitable appearance of senile smile.14
In younger patients, the incisal edges are shaped in the form of a “seagull”, due to
the relative dimensions of the original teeth. In this situation, the incisal edge of the lateral
incisors is 0.5 mm to 1.5 mm above the straight line joining the most incisal point of the
central incisors and canines.43
The digital facial bow proposed in Figure 9 objectively expresses the average facial
lines, the nasal alae and the incisal edge with the patient smiling, proposing a simple
analytical framework for assessing the smile and his relationship with the face, as well as
facilitating the aesthetic planning of the patient.
38
Figure 9.
Figure 9.
Figure 9. Digital design of the facial bow in the photography of the face with patient smiling and displaying mid, nasal alae and incisal edge lines.
PROPORTION OF THE THIRDS OF THE FACE

The evaluation of the facial thirds and the correct
diagnosis of its changes greatly influence the decision for
orthognathic surgery prior to the aesthetic rehabilitation.
Remember that in this evaluation it is important that the lips
to be relaxed for proper measurements. The face is divi-
ded into thirds that define an ideal symmetry which are for-
med by horizontal lines, as highlighted below: (Figure 10)
1. upper third: the hairline to the eyebrow line (above
the eyebrows), corresponding to approximately 30%
of the total length of the face;
2. middle third: the eyebrow line to the interalar line, cor-
responding to approximately 35% of the total length
of the face;
3. lower third: the interalar line to the base of the chin,
corresponds to approximately 30% to 35% of the to-
tal length of the face.
Figure 10.
Figure 10. Patient photography with lips at rest position with the tracings of the lines that divide
the face into thirds, for analysis of horizontal ratio.
39
Figure 11b.
Figure 11a. Figure 11c. Figure 11d.
Figure 11.Patient presenting with decreased lower third; initial photo with tracings dividing the face into thirds (a) and initial photo of the smile showing tooth wear and loss of dimension (b). Post-rehabilitation
photographs showing the established aesthetics (c) and harmony between the thirds of the face(d).
Figure 12a.
Figure 12c.
Figure 12b. Figure 12d. Figure 12e.
Figure 12. Patient with increased lower third as a result of vertical maxillary excess that declined to to submit to orthognathic surgery (a-b). Completion of the mock-up (c) guided the decision for
periodontal cosmetic surgery associated with porcelain veneer veneers, with limited results, though harmonic and in accordance with the patient’s expectations (d-e).
40
The thirds are within a vetical range of 55 mm to 65 mm. Most often, the upper third is smaller than the others in
normal faces; however, in some situations, the patient has degrees of baldness that prevent the use of this reference. For
these common variations, the third is not important in the reference analysis.
The increase in the lower third is often found in cases with vertical maxillary excess and Class II malocclusions. By
analogy, the decrease in the same third is associated with vertical maxillary deficiency, mandibular retraction associated
with deep bite and loss of vertical dimension. (Figure 11)
This area of facial analysis is extremely important in the surgical orthodontic diagnosis and treatment planning. A
classic example are patients with vertical maxillary excess, increased lower third, which are generally associated with gin-
gival display greater than 3.0 mm. In this situation, the best approach is to carry out the orthognathic surgery prior to the
aesthetic rehabilitative interventions, whether they are prosthetic or surgical-periodontal. However, the patient’s decision on
whether or not undergo orthognathic surgery is sovereign and should be the focal point for proposals for new treatment
modalities. The exclusion of orthognathic surgery as first choice encourages the establishment of a second treatment
option, having the mock-up as facilitating instrument in that decision.This option involves performing periodontal cosmetic
surgery associated with full ceramic veneers, with limited results.5 (Figure 12) However, and before the patient’s decision
to refuse to undergo orthognathic intervention, the result, though limited, still promotes a pretty nice change and within the
limits of technical feasibility available.
Equality of the middle and lower third should not be used as the determining factor for changes in facial height. In fact,
the lower third of the face is the most important for facial aesthetics, and thus the occurrence of variations in display of inci-
sors and the interlabial space in the lower third are more important in the evaluation of equilibrium and equality of thirds..5,22
With the lips relaxed, the subnasal (Sn), the upper
lip (Ls), the lower lip (Li) and soft tissues of the mento (Me)
divided the length of the lower lip into thirds.6 (Figure 13)
As a general rule, the length of the upper lip must be half
of the length of the lower lip (skin and vermillion).56
The normal length of the Sn line to the upper rim of
the Li is between 19 mm and 22 mm and involves the
length of the upper lip, which is anatomically shorter (less
than 18 mm, approximately), promotes increased interla-
bial distance at rest and consequently the display of the
upper central incisors which is aesthetically desirable. This
situation can not be confused as the vertical maxillary ex-
cess and increased lower third.5
Figure 13.
Figure 13. Frontal photograph showing length discrepancy of the relationship between upper
and lower lips greater than1:2.
41
Figure 14a. Figure 14b. Figure 14c
Figure 14. Profile photography of patients with different classifications: normal (a), convex (b) and concave (c).
PROFILE VIEW
The profile can be evaluated by joining three points (glabela, subnasal and pogonion)
and the so formed internal angle. The overall harmony of the forehead, midface and lower
third is evaluated with this angle. This analysis also becomes fundamental for the definition
of conventional rehabilitative interventions or to the prior indication of orthognathic surgical
procedures: (Figure 14)
1. normal: forms angle of approximately 170º; (Figure 14a)
2. convexity lower than 170 ° as a function of most posterior position of pogonion and
suggests skeletal Class II. A Class II or convex profile patient, has little dominance of
a central incisor; and (Figure 14b)
3. concave: greater than 170 ° as a function of most anterior position pogonion and
suggests skeletal Class III. (Figure 14c)
Other profile references are used to evaluate the harmony of the face and its conse-
quences, such as the nasolabial angle.
This angle is formed by the intersection of the anterior portion of the upper lip and
subnasal columella. The factors to be considered in the planning to properly evaluate this
angle are as follows: fformed by a line tangent to the base of the nose and another tangent
to the outer edge of the upper lip, corresponds to 90º to 95º angle in males and 100° to
105° in females. This gender difference could be explained by the occurrence of the nose
tip slightly pronounced in women. Still, whenever a patient has natural teeth or dentures
labially inclined, the upper lip is also buccally projected, in a 1 to 0.4 ratio; ie for each 1.0
mm flaring of the teeth, the lip is buccally projected 0.4 mm. In females, this modification
of the nasolabial angle provides a masculine profile.5,6 (Figure 15)
42
Figure 15. Photograph of two patients showing the nasolabial angle and the difference between genders: female (a) and male (b).
LIPS
DENTOLABIAL ANALYSIS
The teeth, visible during wide smile and during speech, are framed by the lips. The
orbicularis muscle of the lips lips joins superiorly to the base of the nose, to the nasolabial
folds laterally and inferiorly the mentalis muscle. When compared to the upper lip, the
lower a tendency has to be larger, full, broad and elastic.A vertical depression previously
mentioned in this chapter, known as “philtrum”, is located in the upper lip and has great
relevance in the analysis of the facial and dental midline.
The philtrum length, measured from the subnasal angle to the lip vermillion, is 2.0
mm to 3.0 mm less than the height of the commissures to the horizontal line that touches
the subnasal angle. This is attractive and desirable from the aesthetic point of view, and
also determines increased display of the central incisor with the lips at rest.
During smile, the lips should move uniformly with the horizontal plane, and therefore
be parallel to the interpupillary line, which, remember, is the facial reference plane.22 In
cases of irregularity of both sides of the upper lip during the smile, one should consider
the possibility of adopting the horizontal plane as a reference. This scenario and its conse-
quent relationship with a larger dental and gingival unilateral display becomes relevant for
surgical planning and prosthetic rehabilitation, because sometimes having it as a reference
and seeking harmony based on such disharmony promotes disastrous results from the
aesthetic and biological point of view, obtaining tilted smiles.
Variations the lip position may depend on ethnic and/or gender differences, espe-
cially in size, contour, shape and position in the range of natural dentition. These variations
may occur depending on the shape, length, the activity of the lips and their support, which
is based on the position of the alveolar process and teeth.27 The lip profiles may also be
affected by the occlusal relationships (Class I, II and III). Thus, the E line, which connects
the tip of the nose to the tip of the chin, should be evaluated, and the natural appearance
43
provided by the position of her upper lip, which is 4 mm shorter than her lower lip, 2.0 mm.
Many variations are possible, but every lip position is found to be normal provided that it is
located posterior to the line E.11 (Figure 16)
The teeth and the alveolar process provide all the anatomical support of the lips,
while the anterior superior teeth support the lower half of the upper lip. In fact, it is the too-
th position, not the position of the incisal edge, which establishes the relationship to the
upper lip, and this has been seen in studies that showed that in 70% of cases the support
does not come from the incisal third, but from the remaining two thirds of the maxillary
incisors. The maxillary teeth are the primary support of the upper lip, but this can vary de-
pending on the type and shape of the lip. The position of the teeth have a greater effect
in thin, prominent lips when they are compared with thick and retracted lips.10 (Figure 17)
The correlation between lips, philtrum and central incisors is frequent and fundamen-
tal to establish the dominance of the centrals, which promotes a more pleasant aesthetics.
As an example, bulky lips require longer and voluminous central incisors for proper display
at rest.22 This condition favors positioning correcting the teeth in situations of tiltings with
ceramic veneer veneers in which the patient does not accept undergoing orthodontic tre-
atment without interference of the facial aesthetic outcome. In contrast, thin and short lips
require finer central incisors, which prevents their overdisplay at rest.22 In this condition, it
requires greater respect to morphology to be established, since the emergence profile to
the three vestibular slopes, under the risk of changing the lip and facial aesthetics.
DISPLAY OF THE ANTERIOR TEETH

The lip position at rest is that in which the patient is in an upright and natural position
of the head with jaw and lips relaxed. There are no tooth contacts, and a a slight interla-
Figure 16a. Figure 16b. Figure 17.
Figure 16. Patient photograph showing the ideal tracing of line E: with this line, the upper lip should be 4 mm below that line, and the lower, 2 mm below (a). In the second patient, the upper lip almost
touches the line and the lower surpasses showing a mentus impairment (b).
Figure 17. Patient with mock-up on the right hemiarch and without mock-up on the left hemiarch, which shows the difference in lip volume when there is an increase in the volume of anterior superior
teeth.
44
bial separation is observed. To observe this position, the literature suggests the repeated
speech of the letter “M”. When pronouncing that sound the patient touches the lips, whi-
ch, when separated, return to the lip position at rest.22 Another possibility is the tip inwhich
the patient blows softly with the lips sealed, and the end of this process also dictates the
position of lips at rest.
This reference condition is of utmost importance in defining the incisal length of the
anterior teeth. It is also the position in which is diagnosed what is referred by the lay as
“young smile” or “aged smile”. Such expressions emerged from the fact that there is less
display of the upper teeth associated with aging, either by wear of tooth elements or the
loss of perioral muscle tone. Such a reduction of display of superior-anterior teeth culmi-
nates in an display of the anterior-lower teeth. (Figure 18) In addition to this relationship
with aging, there is a difference of dental display with lip position at rest between men and
women. It is normal to have more dental display in females than in males.22,27 This is be-
cause women usually have shorter lips than men. The normal range is 1.0 mm to 5.0 mm.5
Figure 18d. Figure 18e. Figure 18f.
Figure 18. Photograph of patient’s face which does not expose the maxillary central incisors with lips at rest (ab) and smile photo (c). Facial photograph of the same the patient’s rehabilitated with
porcelain veneer veneers without preparations from 26 to 16, showing display at rest compatible with gender and age (d-e) and the harmonious smile (f-h).
Facial and artistic photographs by Dudu Medeiros.
45
Figure 18g.
46
Figure 18h.
47
Figure 19. Photograph of a male patient which shows the amount of exposure of the central incisors in optimal rest for men, about 1.91 mm (a). For women, this value reaches 3.4 mm (b).
Vig & Brundo71 reported that maxillary incisors are more displayed on average in women (3.4
mm) when resting than in men (1.91 mm) and that in young patients they are more visible than in
middle-aged patients (3.37 mm against 1.26 mm).22 (Figure 19)
FULL SMILE POSITION

At full smile, some dental-labial features can be seen such as the gingival display (smile
height); gingival balance of levels; harmonious gingival contour; the position of the gingival zeni-
ths; the buccal corridor; and the occlusal plane relationship with commissure line and the incisal
curvature. During smile, 57% of subjects exhibit up to the second bicuspid, and 20% until the
first molar.18
According to Gurel,28 a pleasant smile is achieved when the angles of the mouth (labial
commissure line) are parallel to the interpupillary line and the incisal plane, with the tips of the
canine gently touching the lower lip. This touch should be added to the the incisal curve coin-
ciding with the lower lip.
SMILE LINE
Defined as the lower edge position of the upper lip relative to the teeth and gingiva, the
smile line defines the amount of tooth and gingiva exposed when the patient is smiling. It is rela-
ted to greater mobility (muscle) of the lip and/or to its length and may be classified as follows:68
(Figure 20)
• low: frequent in 20.5% of the population, the motility of the upper lip exposes up to 75%
the length of the anterior teeth and no gingiva;
• middle: frequent in 69% of the population, labial movement reveals 75% to 100% of the
length of the anteriors and gingival papillae;
• high: 10.5% frequent in the population, the anterior teeth are completely exposed during
the smile and also a gingiva of variable length. At a frequency twice as large in women, it is
suggested that this situation is due to the shorter the length of upper lip (average of 19.5
mm) in relation to men lip (average between 22 mm and 24 mm).
48
Figure 20. Facial photographs of three patients with different smile line heights and hence different degrees of exposure of the teeth and gingiva: Low (a), middle (b) and high (c).
Photos by Dudu Medeiros.
The height of the smile is influenced by age and gender. The older the individual, the
greater the tendency to present the low type.16 This information becomes clinically signi-
ficant, since high smile lines tend to become middle with age, and low smiles become
increasingly lower. In other words, there is a possibility of self-correction for smile “gingival”
over time, and this not happens with low smile.
According to Chang et al.13 and Cracel-Nogueira &Pinho,18 the average smile line is
associated with more aesthetic smiles. Adding up these considerations, it is imperative
that rehabilitative planning, especially surgical, to be based on this concept that the mid-
dle smile line is optimal and that is changeable over time. Thus, small distortions of high
to middle smile lines will be compensated naturally and reach the optimal point through
the years, which could, thereby promote less invasive therapies and quicker rehabilitation
treatments.
Gender also seems to influence the smile height. The literature shows that there is a
greater tendency for women to have middle and high smile line, and men to have middle
and low smile lines.55,59
The presence of a high smile line and disharmonic gingival contour suggests the
clinical indication of periodontal cosmetic surgery to improve the results. In situations of
low smile line, the gingival contour is not decisive and liable to influence the final smile.
Disconsidering this correction depends on the acceptance of the patient to maintain the
contour disharmony, even without obvious display during smiling. Sometimes even without
direct interference on the displayed result, this imbalance is refuted by the patient and its
correction needs to be considered and shown in the treatment planning.
49
When planning anterior rehabilitations one should consider that after the successful
aesthetic rehabilitation treatment in anterior teeth, the maximum elevation of the upper lip
during wide smile, may increase due to increased self-esteem of the patient. The upper
lip line should not then be considered in the first evaluation as a reliable or immutable
reference.28
BUCCAL CORRIDOR
During the smile, not only are the teeth should be considered, but also the illusion
of depth or grading effect provided by the negative space created by the buccal corridor.
Such terminology is defined by the available space in the buccal aspect of the smile of the
posterior teeth until the buccal mucosa. This depth effect is emphasized by the vestibular-
-palatal position of the maxillary canines.26,52,63
Remember that the relationship between the distance of the most lateral points of the
canines and the distance between the angles of the mouth does not have strong influence
on the smile aesthetics, but rather when evaluating the image as a whole. The buccal or
lingua positioning of the bicuspids determines the appearance of a defect.31 (Figure 21)
Overlooking the importance of this space brings smile disharmony, as in the case
of positioning excessive buccal of rehabilitations in the posterior region. This can fill com-
pletely the buccal corridor and change the smooth and natural progression of smile. Con-
versely, an excessively broad buccal corridor also hinders the final outcome, by lack of
buccal volume for premolars and molars.22 The observance of this initial clinical condition
is determinant for the indication of ceramic veneer veneers in the posterior teeth, for the
broad buccal corridor correction, because in case of installation for veneers in anterior
superior teeth, there is an inevitable projection of the maxilla, which strongly highlights the
initial defect shown. The opposite takes place when the indication is solely for the delivery
of the ceramic veneers only of the anterior teeth.
Figure 21. Photographs patients who illustrating the three possible situations the buccal corridor analysis of: large (a) and narrow (b); and from two situations that change the natural progression of
harmonious smile, and optimal (c).
50
Ideally, the contour of the gingival margin outlined by the cervical levels of the ma-
GINGIVAL ANALYSIS
xillary canines and central incisors should be parallel to the incisal edge and the curvature
of the lower lip.22
The gingival zenith is the most apical point of the gingival contour and usually is lo-
cated distally to the long axis of the teeth. However, the exact distal positioning may vary
due to the dental morphology, as well as by the shape of the cervical contour, determining
the shape and size of the interdental papillae as well. The papillae, in turn, depends upon
the presence of the diastema or even small interdental spaces, which is able of generating
short and flat papillae, rather than the traditional long and inverted triangular shaped base.
An aesthetically pleasing gingival contour occurs when the gingival zenith of the
maxillary central incisor is symmetrical to the canine and ranges from 0.5 mm to 1.5 mm
apical to the lateral incisor. In this conformation, the zeniths of the anterior superior teeth
are characterized as the vertices of an imaginary triangle, which gives the balance of the
gingival components. Lack of this harmony, verified by the absence of formation or inver-
sion of this triangle, suggests the need for surgical correction of the tissue contour, in order
to optimize the aesthetic result. The correct placement of the gingival margin will influence
the tooth shape definitively.43 (Figure 22)
Clinical situations in which the gingival margin of the central and canines are on the
same plane, or when the margin of the canines is positioned slightly above the edge of
the central incisors and the margin of the lateral incisors is below both the centrals and ca-
nines, are deemed harmonic conditions. If the level of the canine gingival margin is below
the level of the central incisors or the edge of the laterals is higher than both teeth, this is
to be considered a disharmonious condition with apparent reversal lines. (Figure 23)
These variations in the gingival contours are visible particularly in patients with a high
smile line completely exposing the anterior teeth along with a strip of gingiva of variable len-
gth of approximately 1.0 mm to 3.0 mm.37 The acceptability of this exposed gingiva ranges
from 4 mm for lay people with a tolerance of up to 2 mm for clinicians.38 More recently,
Kaya & Uyar35 revealed that the appeal of a smile is directly related to gingival display and
consequently influenced by the smile arc, and the opposite is also true, as the smile arch
is influenced by the gingival display. The results revealed that, in situations wherein the
Figure 22. Figure 23.
Figure 22. Patient with optimal configurations of the gingival zenith, which greatly influence the final shape of the teeth.
Figure 23. Demarcating zenith positions of anterior upper teeth, showing total bilateral disharmony and discrepancy with the aesthetic gingival principles.
51
amount of gingival display is insufficient, it is more appropriate to use more triangular arches (more closed). On the other
hand, when the amount of display is excessive gingival, parabolical smile arches are more preferred.
Situations where such a gingival display is greater than 3 mm are known as gingival smile. Its etiology is related to
different factors: (1) passive incomplete or altered eruption; (2) excess gingival growth; (3) maxillary anterior or complete
vertical excess (hyper-maxilla); (4) insufficient length of crown; (5) short upper lip; and (6) hyperactivity of the upper lip.41
Possible corrections for the gingival smile include periodontal surgery, orthodontic corrections, orthognathic surgery,
and applicationof botulinum toxin (Figure 24) and application of orthopedic cement. The definition for the type of treatment
will depend on the variety of existing medical conditions,50 the generated clinical consequences, and above all upon the
patient’s compliance to the proposed treatment planning.
Figure 24. Patient with gingival smile and color and shape deficiencies of teeth (a). The use of botulinum toxin in the elevator muscle of the upper lip and nose wing (b) promoted reduction of the gingival
smile (c). Final photograph of the patient with l installed aminates (d).
Figure 25. Patient with thick lips and gingival smile (a) in which excess gingival exposure was eliminated by surgery to increase the clinical crown, and associated with dental bleaching (Power
Bleaching®, BM4, Brazil), with predictable and satisfactory results.
52
Except for complex cases of vertical maxilla excess, the treatment of the gingival smile usually recommended and that
should be firstly considered is clinical crown lenghtening through the removal of marginal support structures. (Figure 25)
However, particular situations will advise the use of specific surgical procedures. In the presence of excessive soft and bone
tissue, surgical techniques for such situations are gingivoplasty, osteotomy and osteoplasty, with total flap, mixed or without
flap elevation, ie the flapless technique.33 This step is critical in determining the gingival contour, the zenith positioning and
hence the dental morphology is be established after rehabilitation. Thus, the mock-up becomes an essential tool to guide the
surgical process depending upon the advanced approval of the size and morphology of the tooth. (Figure 26)
In some cases, the upper lip may not possess adequate bone support for the dynamics of the smile by shortening
when it accommodates in the depression of the anterior maxillary process creates a broader smile or even during speech.
In these situations, the literature has recommended the association of the clinical crown lenghtening surgery with orthope-
dic surgical cement to provide lip support and limit the elevation of the upper lip during smile.50 Such a situation can also
be compensated for by the surgical reduction of bone volume of the anterior of maxilla process and the posterior regions
in which the lip seats. The elimination of this accommodation position promotes only lip sliding in the maxilla, strongly
controlling the gingival smile. Another relevant factor is to maintain the lip thickness with decreased bone volume when
smiling. The lip, when accommodating itself within the anatomical depression invariably becomes thin by inversing to the
full muscle movement.
Figure 26. Patients with thin lips and gingival smile represent a more complex condition (a), whose solution should be properly planned and tested through the use of a mock-up. In this case an indirect
acrylic resin mock-up (b), showing the need for gingival and incisal lengthening. The same mock-up was also used as a surgical guide for achieving the clinical crown lenghtening surgery (c), whose
result improved the gingival display, but was unable to solve it completely. The ceramic veneers complemented the rehabilitation lengthening to incisal, producing a more harmonious outcome (d).
53
WIDTH/LENGTH RATIO
DENTAL ANALYSIS
The relationships and ratios of the anterior teeth determine an equilibrium for the aesthetic
perception of a smile.
Lombardi43 introduced to Dentistrythe application of the golden proportion. Although the
concept of the golden proportion has fulfilled an important role, its application can not be rigid
and should not be used to define a rehabilitation planning, disregarding individual modifying fac-
tors.4,20,29
The golden proportion produces results with narrower canines than desired, with less ple-
asant relationships from an aesthetic point of view.43,58 However, Murthy & Ramani50 revealed the
possibility of applying this rule when considering and carrying out adjustments according to the
ethnicity of the population.
Thus, the authors define the ideal dimensions of the maxillary central incisors (CIs) as the
starting point for planning being that they are more representative elements of the smile. There are
different manners to determine the ideal width and length of the CIs. According to Fradeani,23 they
should present an average width of 8.3 mm to 9.3 mm. Other researchers suggest possible re-
lationships of dental measurements with facial and intraoral measures, in order to assist clinicians
in this difficult task of determining the width of the anterior superior teeth.3,19,25
The width of the central, lateral incisors and canines are highly correlated with the interpu-
pillary distance and the combination of interpupillary and interalar distances,30,32 along with the
inter-commissure width and the distance between the medial corner of the eye (Intercantal).25
However, Strajnic, Vuletic &Vucinic67 reported not to rely on the application of parameters such as
the intercantal distance and the interalar width, the same was shown by Hasanreisoglu et al.,29
who highlighted the need for correlating the width of the anterior superior teeth with the charac-
teristics of race and gender.
In the face of disagreements, the ease of use and relevant and desired individualized plan-
ning for each patient, the authors dictated as a rule using the interpupillary distance as a fixed and
personal facial reference for determining the width of the central incisor.12 (Figure 27) The achieve-
ment of the width of the maxillary central incisor occurs by dividing the interpupillary distance by fi-
xed factors, ranging from 6.6 to 7.2, defining the maximal and minimal ideal widths, respectively.12
The centrality for determining tooth width12,19 occurs due to the ease of determining the tooth
height, since the smile height can be determined by the upper lip, which is a reliable anatomical
reference.
The relationship between the widths of the teeth is 100% for the CI; that of the lateral in rela-
tion to it is 74%; and the width of the canine is 88% relative to the central (may use 80% to 90%).
These numerical mathematical relationships should not be overstated rigidly and with precision,
due to the fact that there are variations in the literature caused by systematic errors during shoo-
ting. This statement explains the slight variation of the results from Preston,59 when comparing
the relationship suggested above, with the lateral incisor width in relation to the CI (67%), and the
width of the canine relative to the central (84%).
Studies on tooth proportion have concluded that the length of the CI is 25% to 33% gre-
ater than its width. That is, to achieve the length it becomes necessary to multiply the wid-
th of CI by a coefficient of 1.25 to obtain the minimum length or by 1.33 to obtain the maxi-
mum acceptable length.14,15,22 (Figure 28) The centrals and canines have similar coronal heights
54
Figure 28a.
Figure 27. Figure 28b.
Operative Dentistry – Ideal Dimensions

Central Incisor Lateral Incisor Canines Length x Width - Ratio
63 Lateral Width Canine Width 100% 75% 85%
Width of the Width of the

Central Incisor Central Incisor
0,5 or = CI
C.I. Width C.I. Width
-0,5 to 1,5mm
-25% -15% 7,9
÷ 6,6 ÷ 7,2 6,97
(x0,75) (x0,85) With Diastemata
9,54 8,75 Check with D.I if it is greater the maximum
acceptable refer to Orthodontics
x1,33 x1,25 x1,33 x1,25

Lateral Length Canine Length
12,68 11,92 10,93 11,63
Equal to the Length of Equal to the Length of
the Central Incisor the Central Incisor
Minimum and x y z
maximum acceptable
length of the central incisor x+y+z= 18,6 ÷ 2 = 9,3
-0,5 or equal
-0,5 Measurements For Wax-up
Selected Design of the C.I. -0,5 à 1,5mm -0,5 à 1,0mm
Width Length -1,0 -0,5 11,62 10,1 11,12

11,62
9,3 INCISAL CERVICAL Final Value = 11,12
9,3 6,97 7,9
Final Value = 10,1
Figure 28c.
Table 1. Calculation for obtaining the width and length of the maxillary central incisors.
÷ 6.6 = maximal width x 1.33 = maximum length of the central incisor
INTERPUPILLARY of the central incisor x 1.25 = minimal length of the central incisor
DISTANCE ÷ 7.2 = minimal width x 1.33 = maximum length of the central incisor
of the central incisor x 1.25 = minimal length of the central incisor
Figure 27. Photograph representing the correct way of measuring the interpupillary distance of the patient: head straight up, staring at a fixed point
right in front, and the digital caliper placement at the center of both pupils.
Figure 28. With the measurement of the interpupillary distance, two central incisor width values are obtained when dividing by 6.6 (a) or 7.2 (b), and
two different lengths can be obtained from each of these values, when the width is multiplied by 1.25 or 1.33. Figurewith the patient’s calculations
illustrating the chapter showing the obtaining of widths and lengths from the interpupillary distance,(c).
55
(range of about 0.5 mm) and a range of 1 mm to 1.5 mm longer than the lateral inci-
sors.43,65 (Figure 29)
In an ideal composition, two lines which join the cervicals and the incisal edges of
the maxillary centrals and canines should include the laterals, ie ideally the laterals cannot
break through those lines, neither by the gingival or incisal.14
Obtaining an ideal width/length aspect ratio is not always possible without ortho-
dontic movement. Thus, one can rehabilitate clinical situations of the atresic arch without
room for increasing the width of the teeth with alternatives such as the use of orthodontic
separators, for a period of 24 h, promoting the creation of a space for the flaring of the
teeth to be restored provisionally with composite resin, to maintain the space until the
rehabilitation is completed.
Regarding tooth crowding, Fradeani22 advocated that in rehabilitation without room
for the six anterior superior teeth, the laterals should be narrowed. However, the authors
have stated the ideal tooth to be modified for corrections of position and arrangement dis-
crepancies, should always be the canine, because its distal portion is not visible. Another
possibility to accommodate the teeth in the arch with little room is to rotate the laterals,
always preserving the harmony of the dominant teeth of the smile, the central incisors.
It is worth remembering that in both the above conditions, the dental anatomy would
be wrong and not consistent with the natural anatomy.This means that attempting to solve
aesthetic problems through compensations and changes in the anatomy of individual tee-
th is not always the ideal. Treatments correcting this initial condition, such as orthodontics,
should be preferred. If this also is not possible, then the patient should be aware of the
case limitations.28 (Figure 30)
Figure 29c.
Figure 29. From the ideal proportions of the central incisors of each patient it is possible to recreate shapes and sizes of the remaining teeth,
creating a harmonic distribution, based on the actual measures obtained in the patient. With this new shaping a wax-up and mock-up can be made
to explain to the patient all the possibilities for resolution of the case. In this case, direct composite resin mock-up was fabricated, along with smile
(a), and intraoral (b) photographs. See the formation of the imaginary triangle of zeniths (c).
56
Panoramic view
Figure 30a.
Labial-palatal cross-sectional slices - Real size (1:1)
Figure 30b.
Figure 30c.
3D reconstructions
Right buccal view Occlusal view
Figure 30d.
Figure 30e. Figure 30f.
Figure 30g. Figure 30h. Figure 30i.
Figure 30j. Figure 30k.
Figure 30a-k. Surgical stage of the case shown in this chapter: clinical crown lenghtening, tooth extraction of #53 and fixture installation.
57
TOOTH TYPE
The tooth type refers to form. According to Lombardi,43 choosing the shape of teeth
for rehabilitation is based in compliance with the shape of the face of the patient. Other
parameters are also used when choosing dental forms such as gender, personality and
age.28
Thus, the first techniques to select tooth shape appeared in the late nineteenth cen-
tury, influenced by the theory of the four moods.7,71 Based on the observation of physical
and emotional characteristics, subjects were classified into one of the following moods:
sanguine, phlegmatic, choleric or melancholic. The different tooth shapes corresponded
to different moods.73 However, based on Williams’s work, the mood theory was discredi-
ted by the scientific community.72
Theoretically, the existence of a typical woman’s tooth may be assumed to be more
rounded, such as ovoids, and a purely masculine tooth, square, as demonstrated by Bur-
chett and Christensen.9 However, it seems there is no exact correlation between gender
and tooth form because of its prevalence data may not be the rule, and there is no reason
to state that these differences are easily noticeable from casual observation.8
The observation of a large number of natural tooth forms clearly demonstrates the
countless variations of tooth forms and that these characteristics differ in the most diverse
ways. Thus, for teaching purposes, there are three main types of tooth forms: ovoids,
triangular, and squared.34,72
To better understand these forms one must know the morphology, the marginal
ridges defined as determinants enamel ridges on the prominence and visualization of the
teeth. Between the ridges, there is a flat area, especially in the maxillary incisors. At the
proximal aspect of the ridges, regardless of lighting, shading occurs, from which the op-
tical perception of the tooth volume is defined. For this reason, the use of articulated twin
speedlights or still lighting for clinical shots is indicated, in order to highlight the marginal
ridges through lateral illumination. Most often, a circular flash is unable to define the details
of the tooth form with precision.28
Table 2 features the three formats. (Figures 31, 32 and 33)
Table 2. Characteristics of the most commonly found tooth shapes.
SHAPE SQUARED OVOIDAL TRIANGULAR

Peripheral contour Straigth Rounded Strait
Marginal ridges Sharp and parallel Smooth and converging to incisal Prominent and converging towards the
. . and cervical cervical
Developmental grooves Long mesial and narrower incisal base Without sulcii Discrete concavity between crests
. compared to the distal . .
Flat area Greater and uniform Greater in the middle third Greater in the incisal third
Zenith Distal to the crown long axis Between middle and distal thirds Central
Gingival contour Slightly rounded or flattened in the middle Completely rounded Triangular
. third . .
Shadow area Small, uniform and clear transition to Smaller in the middle third and Greater in the cervical third and quite
the plane area smooth transition to flat area clear transition to the flat area
58
Figure 31. The photograph represents a natural squared tooth (a) and a wax-up where the goal was to obtain a squared tooth shape (b) with its greater light reflection and minor shade area (c), causing
the impression that the tooth is wider.
Figure 32. Photography of a natural ovoid tooth (a) and wax-up of the same previous mouth with ovoid teeth (b), now presenting outline and smoother configuration with almost no shaded area (c).
Figure 33. The natural triangular tooth is shown in Figure (a), and the same teeth from previous waxing represent now that format, showing the change of the flat area (b), shape of the crest and the
zenith position (c).
Due to the subjectivity of tooth shape and numerous individual variations, the ultimate
goal should be the making of the diagnostic wax and the completion of the mock-up, for
the patient’s subsequent approval.43
59
PROXIMAL CONTACT AREAS IN THE ANTERIOR DENTITION
The proximal contact area is the wide area where two adjacent teeth touch each
other. Between the anterior maxillary teeth, the length of this area is not equivalent. Ac-
cording to Morley,48 proximal contact areas should ideally be of approximately 50% of the
length of the central incisor and between both centrals; 40% between the central and
the laterals; and 30% between the laterals and the canines. In a more recent study, the
percent rule was suggested to be 40-30-20, which indicates the relationship between
the anterior teeth where the largest contact area occurs between the central incisors (40),
and the narrower contact which is seen between the lateral incisor and the canine (20).64
(Figure 34)
The most incisal aspect of the contact area is named the point of contact. Such
contact points move apically as we move toward the posterior region. However, this rule
should also be individually analyzed and in accordance with the tooth morphology present
or established for the rehabilitation. Squared teeth have longer contact area proximal than
triangular teeth as well as point of contact more incisal while in triangular teeth it is positio-
ned more towards the middle third in teeth ovoid.
The contact area and the interproximal point of contact is also variable for rehabili-
tation of areas with diastema, especially with converging faces to incisal. In these situa-
tions, the interdental spaces (diastema) “camouflage” the observation of an aesthetic and
more severe morphological discrepancies: the gingival papillae. They present to be shorter
when compared to the ideal papillae and planned and format different from the ideal trian-
Figure 34.
Figure 35.
Figure 34. Schematic representation of the different contact areas found in the anterior superior teeth, showing proportional reduction from anterior
to posterior.
Figure 35. Schematic of the ideal size of the embrasures of the anterior teeth drawing: the cervical embrasures should decrease as we move away
from the midline, while the incisal embrasures should increase in the same direction.
60
gular shaped; however, they have deeper gingival sulcus and greater tissue volume, which
facilitates their handling during the interim phase and after the delivery of the ceramics. As
discussed in Chapter 6.1, to minimize or eliminate the formation of black triangles or “black
spaces”, the contact area should be extended as more cervically as possible; therefore,
squared teeth, and especially ovoid are preferred for rehabilitating these situations.
From the point of contact, two adjacent teeth diverge and form the incisal embra-
sures,28 the spaces found between a tooth and its adjacent in the incisal edge of anterior
teeth. Its width is determined by the contact area of the proximal position, i.e., increasing
in size as they move away from the midline. Ithis makes the incisal embrasure formed
between both smaller in central incisors than in the central and lateral incisors, which, in
turn, is smaller than the embrasure formed between the lateral and canine. On the other
hand, the cervical embrasures decrease in their relative size as we move away from the
midline.45,28,47 (Figure 35)
The incisal embrasures can also affect the perception of the length, width and the
incisal edge.A change in the incisal edge can provide a lowered or increased illusion of
width. Worn teeth produce a loss of the incisal embrasures and create a short and wide
tooth aspect. In diastema closure situations, an accurate job incorporating tooth morpho-
logy makes it necessary to create the optical illusion of narrower teeth. To this end, wide
open incisal embrasures are manufactured, creating teeth which are preferably ovoid.28
Just like working with opened embrasures, the marginal ridges are manipulated as well as
the area of light reflection to create the aspect of narrower teeth. (Figure 36)
Figure 36a.
Figure 36b.
Figure 36a-b. Diagram showing the displacement of edges, which gives from optical illusion narrower or wider teeth with teeth of the same width.
61
DENTAL AXES
The gingival zenith, as described above, is the most apical point of the gingival contour
which is usually distally located to the long axis of the teeth, depending upon the dental
morphology. In this ideal anterior dental composition, the axial inclination of the anterior teeth
normally produces coronal convergence and apical divergence from the midline. That is, the
incisal third is inclined towards the mesial and the cervical region towards the distal aspect.
The lateral incisors are inclined more distally in the apical direction than the centrals.22,45 Note
that these are basic features in relation to the long tooth axis, and that the optical axis can
change in accordance to the angle of observation. (Figure 37)
Figure 37b.
Figure 37a. Figure 37c.
Figure 37. Patient presenting aesthetically compromising smile (a) with dental axes off the optimum standards(b). Diagram with the layout of the ideal tooth axes (continuous line) and present (dashed
line) for this patient (c). Correcting these axes leads to a harmony of teeth with lips (37d) and each other (37e), providing greater beauty (c).
62
OPTICAL ILLUSION
Through optical illusions created, contrasts can be enhanced and proportions can
be distorted. In routine practice, misaligned teeth, slightly changed gingival contours and
gingival recession occur very often. These variations may limit the use of a trustworthy rule,
and where it is not clinically possible to establish the correct tooth proportion the clinician
may create the illusion of having modified the tooth size without having actually carrying it
out (illusion perception).
In the marginal ridges above two major lines it is possible to differentiate to each
other. The apex line of greater curvature lies well outside, and the second line, more cen-
tral, internal from vault is the largest marginal ridge towards buccal. This marks the second
line flat, strategic area for light reflection and disguises the appearance of anterior superior
teeth. The external line of the vertex coincides in respect to the lateral edges of the shading
called shaded area, from which the optical perception of the tooth volume is defined.
The light that directly reaches the buccal surface between the ridges is reflected,
while it reaches the outer areas of these lines it is deflected up and in this way is less no-
ticeable. By modifying the orientation and arrangement of the internal lines of the ridges,
the area of reflected light may be increased or decreased,21 which gives the visual aspect
of broader or narrower teeth. (Figure 38)
Figure 38.
Figure 38. Diagrams representing the flat area based on position of the edges. The top drawing shows the vertical edge displaced to the proximal
surfaces obtaining a large flat area and therefore more light reflection (contraindicated in patients with diastema). The bottom drawing represents the
displacement of the edge more towards the medial third, offering an optical illusion of a narrower tooth.
63
According to Touati,69 in this manner, the tooth shape may also influence the perception of dimensions. To make the-
tooth apparently narrower, it is necessary to build a smaller flat area. In other words, there is least amount of space between
both internal lines of the marginal ridge. This visual phenomenon occurs because, with the reduction of the flat area less
dissipation of the light reflection takes place, which gives the optical illusion of a narrower tooth. Otherwise, by increasing
the area, there will be greater light reflection and hence the aspect of a wider tooth. This analogy to light reflection also
applies to surface texture and brightness of the teeth. The aesthetic rehabilitation and subsequent distribution of spaces
must pass through the analysis of the amount of brightness present in the ceramics, as well as its texture, favoring the
control of reflected light capable of creating the aspect of narrower or wider teeth.
Finally, the projections of the internal vertex lines meet virtually at some point as they always converge in the cervical
region of the tooth crown and create a smooth arch at the same height as the contralateral. Knowing these lines and their
extensions allows for building rehabilitations with more predictable and more natural morphology.28 Decisively, there is the
coincidence of the positioning of the gingival zenith and the cervical end of the distal marginal ridge on the maxillary central
incisors, as in other anterior superior teeth. (Figures 39, 40 and 41)
Figure 39. Initial photograph for comparative analysis with the achieved result (a). Resolution of the clinical case illustrated in this chapter with intraoral photos and final smile, showing the beauty and
harmony achieved with the rehabilitation (b-e).
Figure 40. Design of the digital facial bow in the initial photo and the exact same bow in the final picture, which shows that the aesthetic goals based on facial references were achieved.
Figure 41. Initial and final facial photographs of the case shown in this chapter.
Photographs by Dudu Medeiros.
64
Figure 41a.
65
Figure 41b.
66
Figure 41c.
67
1. Ahmad I. Anterior dental aesthetics: Dental perspective. Br Dent J. 2005;199(3):135-41.
REFERENCES
2. Ahmad I. Anterior dental aesthetics: dentofacial perspective. Br Dent J. 2005;199(2):81-8; quiz 114.
3. Al Wazzan KA. The relationship between intercanthal dimension and the widths of maxillary anterior teeth. J Prosthet Dent.
2001;86(6):608-12.
4. Ali FM, Jamani KD, Agrabawi J. Geometric and mathematical proportions and their relations to maxillary anterior teeth. J
Contemp Dent Pract. 2006;7:62-70.
5. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning: part II. Am J Orthod Dentofacial Or-
thop. 1993;103(5):395-411.
6. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning: part I. Am J Orthod Dentofacial Orthop.
1993;103(4):299-312.
7. Berry FH. Is the theory of temperament the foundation of the study of prosthetic art? Dent Mag. 1906;1:405-13.
8. Brunetto J, Becker MM, Volpato CA. Gender differences in the form of maxillary central incisors analyzed using AutoCAD
software. J Prosthet Dent. 2011;106(2):95-101.
9. Burchett PJ Jr, Christensen LC. Estimating age and sex by using color, form, and alignment of anterior teeth. J Prosthet
Dent. 1988;59(2):175-9.
10. Burstone CJ. Lip posture and its significance in treatment planning. Am J Orthod. 1967;53(4):262-84.
11. Calamia JR, Levine JB, Lipp M, Cisneros G, Wolff MS. Smile design and treatment planning with the help of a comprehensive
aesthetic evaluation form. Dent Clin North Am. 2011;55(2):187-209, vii.
12. Cesario VA Jr, Latta GH Jr. Relationship between the mesiodistal width of the maxillary central incisor and interpupillary dis-
tance. J Prosthet Dent. 1984;52(5):641-3.
13. Chang CA, Fields HW Jr, Beck FM, Springer NC, Firestone AR, Rosenstiel S, et al. Smile aesthetics from patients’ perspec-
tives for faces of varying attractiveness. Am J Orthod Dentofacial Orthop. 2011;140(4):e171-80.
14. Chiche GJ, Pinault A. Artistic ans scientific principles applied to aesthetic dentistry: In: Chiche GJ, Pinault A, editors. Aesthe-
tics of anterior fixed prosthodontics. Chicago: Quintessence; 1994. p. 13-32.
15. Chiche GJ, Pinault A. Aesthetics of anterior fixed prosthodontics. Hanover Park: Quintessence; 1996.
16. Cosendey VL. Avaliação do relacionamento entre o lábio superior e incisivos durante a fala e o sorriso [dissertação]. Rio de
Janeiro: Universidade do Estado do Rio de Janeiro; 2008.
17. Peck S, Peck L, Kataja M. Some vertical lineaments of lip position. Am J Orthod Dentofacial Orthop. 1992;101(6):519-24.
18. Cracel-Nogueira F, Pinho T. Assessment of the perception of smile aesthetics by laypersons, dental students and dental
practitioners. Int Orthod. 2013;11:432-44.
19. Dong JK, Jin TH, Cho HW, Oh SC. The aesthetics of the smile: a review of some recent studies. Int J Prosthodont.
1999;12(1):9-19.
20. Ellakwa A, McNamara K, Sandhu J, James K, Arora A, Klineberg I, et al. Quantifying the selection of maxillary anterior teeth
using intraoral and extraoral anatomical landmarks. J Contemp Dent Pract. 2011;12(6):414-21.
21. Forster A, Velez R, Antal M, Nagy K. Width ratios in the anterior maxillary region in a Hungarian population: addition to the
golden proportion debate. J Prosthet Dent. 2013;110:211-5.
22. Fradeani M. Aesthetic rehabilitation in fixed prosthodontics. Aesthetic analysis: a systematic approach to prosthetic treat-
ment. Chicago: Quintessence; 2004.
23. Fradeani M. Evaluation of dentolabial parameters as part of a comprehensive aesthetic analysis. Eur J Esthet Dent.
2006;1(1):62-9.
24. Frush JP, Fisher RD. The dynaesthetic interpretation of the dentogenic concept. J Prosthet Dent. 1958;8:558-81.
25. Gomes VL, Gonçalves LC, Costa MM, Lucas BL. Interalar distance to estimate the combined width of the six maxillary ante-
rior teeth in oral rehabilitation treatment. J Esthet Restor Dent. 2009;21(1):26-35.
26. Gomes VL, Gonçalves LC, Do Prado CJ, Junior IL, Lucas BL. Correlation between facial measurements and the mesiodistal
width of the maxillary anterior teeth. J Esthet Restor Dent. 2006;18(4):196-205.
27. Gracco A, Cozzani M, D’Elia L, Manfrini M, Peverada C, Siciliani G. The smile buccal corridors: aesthetic value for dentists
and laypersons. Prog Orthod. 2006;7:56-65.
28. Gurel G, Coachman C, Calamita M, Morimoto S, Paolucci B, Sesma N. The influence of tooth color on preparation design
for veneer veneers from a minimally invasive perspective: case report. Int J Periodontics Restorative Dent. 2014;34(4):453-9.
29. Hajtó J. Regras de configuração. In: Hajtó J. Anteriores: a beleza natural dos dentes anteriores. São Paulo: Santos; 2008.
p. 189-252.
30. Hasanreisoglu U, Berksun S, Aras K, Arslan I. An analysis of maxillary anterior teeth: facial and dental proportions. J Prosthet
Dent. 2005;94:530-8.
31. Hoffman W Jr, Bomberg TJ, Hatch RA. Interalar width as a guide in denture tooth selection. J Prosthet Dent. 1986;55(2):219-
21.
32. Hulsey CM. An aesthetic evaluation of lip-teeth relationships present in the smile. Am J Orthod. 1970;57(2):132-44.
33. Isa ZM, Tawfiq OF, Noor NM, Shamsudheen MI, Rijal OM. Regression methods to investigate the relationship between facial
measurements and widths of the maxillary anterior teeth. J Prosthet Dent. 2010;103(3):182-8.
34. Joly JC, Silva RC, Carvalho PFM. Reconstrução tecidual estética: procedimentos plásticos e regenerativos. São Paulo:
Artes Médicas; 2010.
35. Kataoka S, Nishimura Y. Nature’s morphology: an atlas of tooth shape and form. Chicago: Quintessence; 2002.
36. Kaya B, Uyar R. Influence on smile attractiveness of the smile arc in conjunction with gingival display. Am J Orthod Dentofacial
Orthop. 2013;144(4):541-7.
37. Kokich V. Aesthetics and anterior tooth position: an orthodontic perspective. Part III: Mediolateral relationships. J Esthet Dent.
1993;5(5):200-7.
38. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental aesthetics. J
Esthet Dent. 1999;11(6):311-24.
39. Kokich VO, Kokich VG, Kiyak HA. Perceptions of dental professionals and laypersons to altered dental aesthetics: asymme-
tric and symmetric situations. Am J Orthod Dentofacial Orthop. 2006;130:141-51.
68
40. Leong SC, White PS. A comparison of aesthetic proportions between the healthy Caucasian nose and the aesthetic ideal.
J Plast Reconstr Surg. 2006;59:248-52.
41. Leong SCL, White PS. A comparison of aesthetic proportions between the Oriental and Caucasian nose. Clin Otolaryngol
Allied Sci. 2004;29:672-6.
42. Levine RA, McGuire M. The diagnosis and treatment of the gummy smile. Compend Contin Educ Dent. 1997;18(8):757-62,
764; quiz 766.
43. Lombardi RE. The principles of visual perception and their clinical application to denture aesthetics. J Prosthet Dent.
1973;29:358-82.
44. Magne P, Belser U. Bonded porcelain restorations in the anterior dentition: a biomimetic approach. Carol Stream: Quintes-
sence; 2002.
45. Malafaia FM, Garbossa MF, Neves AC, DA Silva-Concílio LR, Neisser MP. Concurrence between interpupillary line and tan-
gent to the incisal edge of the upper central incisor teeth. J Esthet Restor Dent. 2009;21(5):318-22.
46. Matthews TG. The anatomy of a smile. J Prosthet Dent. 1978;39(2):128-34.
47. Miller EL, Bodden WR Jr, Jamison HC. A study of the relationship of the dental midline to the facial median line. J Prosthet
Dent. 1979;41(6):657-60.
48. Morley J. A multidisciplinary approach to complex aesthetic restoration with diagnostic planning. Pract Periodontics Aesthet
Dent. 2000;12(6):575-7.
49. Moskowitz ME, Nayyar A. Determinants of dental aesthetics: a rational for smile analysis and treatment. Compend Contin
Educ Dent. 1995;16(12):1164-6.
50. Murthy BV, Ramani N. Evaluation of natural smile: Golden proportion, RED or Golden percentage. J Conserv Dent.
2008;11:16-21.
51. Naldi LF, Borges GJ, Santos LFE, Andrade RS, Batista DG, Souza JB. Aumento de coroa estético associado ao reposicio-
namento labial com cimento ortopédico. Rev Odontol Bras Central. 2012; 21(57):493-7.
52. Orce-Romero A, Iglesias-Linares A, Cantillo-Galindo M, Yañez-Vico RM, Mendoza-Mendoza A, Solano-Reina E. Do the
smiles of the world’s most influential individuals have common parameters? J Oral Rehabil. 2013;40(3):159-70.
53. Parekh SM, Fields HW, Beck M, Rosenstiel S. Attractiveness of variations in the smile arc and buccal corridor space as
judged by orthodontists and laymen. Angle Orthod. 2006;76:557-63.
54. Paris JC, Ortet S, Larmy A, Brouillet JL, Faucher AJ.Smile aesthetics: a methodology for success in a complex case. Eur J
Esthet Dent. 2011;6(1):50-74.
55. Passia N, Blatz M, Strub JR. Is the smile line a valid parameter for aesthetic evaluation?: a systematic literature review. Eur J
Esthet Dent. 2011;6(3):314-27.
56. Paula Jr. DF, Silva ET, Campos ACV, Nuñez MO, Leles CR. Effect of anterior teeth display during smiling on the self-perceived
impacts of malocclusion in adolescents. Angle Orthod. 2011;81:540-5.
57. Perenack J. Treatment options to optimize display of anterior dental aesthetics in the patient with the aged lip. J Oral Maxil-
lofac Surg. 2005;63:1635.
58. Pinho S, Ciriaco C, Faber J, Lenza MA. Impact of dental asymmetries on the perception of smile aesthetics. Am J Orthod
Dentofacial Orthop. 2007;132:748-53.
59. Preston JD. The golden proportion revisited. J Esthet Dent. 1993;5:247-51.
60. Puppin FA. Avaliação quantitativa de medidas dento-faciais relacionadas à altura da linha do sorriso [dissertação]. Rio de
Janeiro: Universidade do Estado do Rio de Janeiro; 2002.
61. Ricketts RM. Aesthetics, environment, and the law of lip relation. Am J Orthod. 1968;54(4):272-89.
62. Rodrigues CDT, Magnani R, Machado MSC, Oliveira Jr OB. The perception of smile attractiveness: variations from aesthetic
norms, photographic framing and order of presentation. Angle Orthod. 2009;79:634-9.
63. Rufenacht CR. Fundamentals of aesthetics. Carol Stream: Quintessence; 1990.
64. Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: Part 2. Smile analysis and treatment strategies Am
J Orthod Dentofacial Orthop. 2003;124:116-27.
65. Stappert CF, Tarnow DP, Tan JH, Chu SJ. Proximal contact areas of the maxillary anterior dentition. Int J Periodontics Res-
torative Dent. 2010;30(5):471-7.
66. Sterrett JD, Oliver T, Robinson F, Fortson W, Knaak B, Russell CM. Width/length ratios of normal clinical crowns of the ma-
xillary anterior dentition in man. J Clin Periodontol. 1999;26(3):153-7.
67. Strajnić L, Vuletić I, Vucinić P. The significance of biometric parameters in determining anterior teeth width. Vojnosanit Pregl.
2013;70(7):653-9.
68. Strub JR, Turp JC. Aesthetics in dental prothetics. In: Fischer J. Aesthetics and prothetics. Chicago: Quintessence; 1999.
p. 11.
69. Tjan AH, Miller GD. The JG. Some aesthetic factors in a smile. J Prosthet Dent. 1984;51:24-8.
70. Touati B. Defining form and position. Pract Periodontics Aesthet Dent. 1998;10(7):800,802-3,806-7.
71. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent. 1978;39(5):502-4.
72. White JW. Temperament in relation to teeth. Dent Cos. 1884;26:113.
73. Williams JL. A new classification of human tooth forms, with special reference to a new system of artificial teeth. Dent Cos.
1914;56:627-8.
74. Young HA. Selecting the anterior tooth mold. J Prosthet Dent. 1954;4:748-60.
69
chapter 3
shade selection and reproduction
in ceramic veneers
Max Schmeling
Ceramic veneers were introduced to Dentistry in the 1930s to solve aesthetic pro-
INTRODUCTION
blems of actors and actresses during footage at Hollywood.38 At that time, inextricably,
there were also the first attempts at reproduction of tooth color. It was the beginning of
Cosmetic Dentistry.
After nearly a century, professionals from different specialties perform the process of
selection and shade reproduction – by the direct or the indirect technique – with no for-
mula which guarantees them complete predictability. For this reason several authors relate
the aesthetic treatments to artwork, rather than to relate them to science.
However, based on scientific evidence, we present in this chapter information inten-
ded to make the chromatic procedure more predictable, upon the underlying concepts
of color, of optical characteristics of natural teeth and the main chromatic evaluation me-
thods used in Dentistry. At the final part of the reading, the main information related to
color reproduction of teeth with ceramic veneers will be described, and the main means
of communication to the ceramist will be presented to guide the clinician in implementing
this important procedure.
In order to having color, i the presence and the interaction of three fundamental fac-
PHYSICS
OF COLOR
tors s necessary: the light source, the object and the observer (Fig. 1). After it is emitted
by a source and hit an object, the luminous energy may be reflected or transmitted to the
eyes of the observer, responsible for capturing and the transformation of such physical
energy into nerve impulses which shall be interpreted by the brain as a chromatic sensa-
tion. The need for cerebral interpretation, however, gives the visual observation method
a subjective character, despite the standardization of the light source and of the object.8
Light source
Viewer
Object
Figure 1.
Figure 1. Light source, object and observer.
72
Light is a form of electromagnetic energy, distinguished from radio waves or mi-
LIGHT SOURCE
crowaves by the wavelength (Fig. 2). Although the human eye is continually exposed to
all wavelengths present within the electromagnetic spectrum, only a small range between
380 nm and 700 nm (nanometers), called the “visible spectrum”, is able to stimulate pho-
tosensitive cells present in the retina and trigger the process of of color perception.35 The
sunlight, also called natural light or white light contains all of the colors, as evidenced by
Isaac Newton, in 1730, when dissociated a beam of white light into seven visible colors
through the incidence in a prism. This luminous capacity plays a key role in the science
of colors and, therefore, should be considered the first option in chromatic procedures.
When this is not possible, we strongly recommend to use lamps that simulate natural
lighting under ideal atmospheric conditions. According to the International Commission
of Illumination (CIE, Commission Internationale de L’eclairage), there are several sources
of light, each and everyone presents its characteristic color temperature, described in
kelvin degrees (ºK). However, illuminants with a temperature of 2,856 ºK (“A Illuminant”)
and 6,500 ºk (“D65 illuminant”) are the most commonly found in supermarkets and spe-
cialty shops, considered as basic sources (Fig. 3).11 The “standard A” illuminants show
yellowish chromatic tendency, resembling a candle flame, and are therefore popularly
Violet Indigo Blue Green Yellow Orange Red
Ultraviolet Infrared
400 nm 50 nm 600 nm 700 nm

Figure 2.
A-Illuminant D65-Illuminant
2856 k 6500 k
Figure 3.
Figure 2.Visible spectrum of the electromagnetic field.

Figure 3.Standard A illuminant (2,856 K) and standard D illuminant (6,500 K).
73
called incandescent. Because the the sum of the light spectrum wavelengths is its color
temperature, illuminants these have low spectral amplitude and should not be used se-
parately in chromatic procedures. On the other hand, “D standard” illuminants have bluish
tendency, higher spectral amplitude and ultraviolet (UV) light wavelengths, being referred to
as fluorescent. In fact, the light spectrum emitted by them is similar to the natural light and,
therefore, should be considered the first option when the latter can not used.30
METAMERISM
Reproduction of tooth shade with a restorative material is possible only due to a
psychophysical phenomenon called metamerism, observed when objects having different
physical and chemical properties interact similarly with the luminous energy, in order to
result in the same color appearance. These objects are called “metameric pairs”.6 In cos-
metic dentistry, the pursuit for the formation of metameric pairs is imperative when trying to
reproduce the tooth shade with a restorative material. Despite the different treatment tech-
niques, either by a direct or indirect method, there are situations that can cause chromatic
differentiation of the metameric pairs and aesthetic treatment failure. These situations,
called “metameric failure”, may manifest in the object or the observer.41
Metameric failures manifested in the object, which could possibly occur after making
the restoration, are usually associated with changing light source (Fig. 4). A common mis-
take is to perform the procedures of shade selection and reproduction under a halogen
light reflector. In this condition, the restoration can perfectly blend to tooth structure, or the
repair ceramic restoration can be perfectly accomplished by using a composite resin, but
under a more intense source of light (eg daylight), different interactions may occur betwe-
en the light, the tooth and the restorative material, resulting in the perception of color.23,26
To avoid this situation, as described above, selection and shade reproduction procedures
require light bulbs with a broad and balanced spectrum light, simulating natural lighting
under ideal conditions.
Figure 4a-b. Metamerism of the object. The patient has a ceramic veneer on tooth 21 photographed under different light sources (left, 2,856 K; right, 6,500 K). Note that under light source with richer
spectrum, a small color difference between the restoration and the tooth can be perceived better.
74
Metameric failures from the observer can occur
when the illuminating source and the object remains cons-
tant, with different observers. It is the result of the complex
psychophysiological mechanism which begins with captu-
re by the eye and is carried out in the cerebral interpreta-
tion of each observer. Thus, the color of a restoration can
be satisfactory for the professional and his patient, and
unsatisfactory for their relatives and friends.6,41 Solving that
problem is feasible but costly. One alternative is by using
electronic devices for measuring of color (instrumental
observation). As we shall see later, the instrumental ob-
servation method is an important aid in the selection and
dental shade reproduction for all levels of professionals,
even though these instruments do not ensure that the me-
tameric failure manifested in the viewer no longer occurs,
due to the subjectivity of the final evaluation of color when
carried out with the visual observation method.
After a lot of training, the control of luminosity in the
surgical ambient and the knowledge the restorative ma-
terial possibilities, still it is up to professional strive in the
procedure, asking for, whenever possible, for the patient’s
and third parties’s opinion during the shade selection pro-
cess. At the end of treatment, even in the face of aesthetic
excellence, the patient can be instructed as to the poten-
tial expression of tiny metameric failures, by the impossi-
bility of completely reproducing the same light interaction
with different materials.
Once having established the spectral quality, another
factor of great importance related to the light source is the
intensity with which the energy reaches our eyes. Simi-
larly, insufficient light intensity complicates the chromatic
evaluation, an exaggerated light intensity also impairs. The
optimal intensity can be measured using a light output me-
ter, called radiometer (Fig. 5), which should remain close
to 100 candles (Watts). Such an intensity is responsible for
promoting an adequate opening of the pupil diameter, key
factor for proper selection and shade reproduction, and
generally corresponds to a unit with 4 fluorescent lamps of
220 watts arranged 2 meters away from the object.1
Figure 5.
Figure 5. Lightmeter.
75
In order to provide increased objectivity to the chromatic communication, for nearly
THE THREE
DIMENSIONS OF COLOR
a century dental literature discussed and supported the three-dimensional classification
of colors proposed in 1898 by the American artist Albert Munsell. In this system, colors
can be expressed by the interaction of three dimensions, called hue, chroma and value.51
HUE
Hue is the most recognizable dimension of color, as IT corresponds to the name of
the color. It is the quality that distinguishes one color from another family, i.e. yellow from
red, or green from blue (Fig. 6). Hue is also described as the main reflected wavelength,
resulting from the interaction between the luminous energy and the object. In Dentistry
is considered the least chromatic dimension, due to the small existing variation between
tooth shades, which are limited to variations between shades of yellow and orange.
Figure 6.
Figure 7.
Figure 8.
Figure 6. Hue
Figure 7. Chroma.
Figure 8. Value.
76
CHROMA
Chroma is the degree of saturation, intensity, purity or amount of pigments present
in a particular hue, making it impossible to compare this dimension among different hues
(Fig. 7). In translucent bodies the chroma is strongly influenced by the thickness of the
material.43 In natural teeth it varies from one tooth to another and between one region and
another in the same tooth.
VALUE
Value is the most difficult dimension of the color of being identified and is the capa-
bility of light reflection of an object. The value scale is limited in its top end by the white
color (high value), which represents the clearest possible color, and on its bottom end by
the black color (low value), representing the lowest brightness which a color can display.
Somewhere in between, there is an achromatic scale, made up of different shades of gray
(Fig. 8). When considering shade selection and reproduction in Dentistry, value is the most
important dimension, since small discrepancies in value are more easily recognizable than
small differences in chroma and hue.
Human teeth have different degrees of translucency, which can vary according to
TRANSLUCENCY
the thickness of enamel and dentin. Similarly, this also occurs with composite resin and
dental ceramics. In other words, increasing the thickness of these tissues and materials
increases their opacity and decreases their translucency.
Defined as the relative amount of light transmitted through a material, the translu-
cency can be translated as an intermediate position between the full blocking of light rays
(opacity) and their total transmission (transparency). Therefore, translucent objects allow
light to pass through them partially varying it to a greater or lesser degree (Fig. 9).43 The
chromatic evaluation in translucent bodies is significantly more complex than in opaque
bodies. Hue, chroma and value are parameters found to be insufficient to describe ac-
curately the optical effects observed in objects that allow for light transmission. For this
Incident light Transmitted light Incident light Transmitted light Incident light
Transparency Translucency Opacity

Figure 9a-c. Translucency.
77
reason, translucency is considered the fourth chromatic dimension applied to Restorative
Dentistry. In this four-dimension concept, value remains as the most important dimension
of color, and secondly the translucency.16
In addition to thickness, another factor that influences the translucency of the teeth
is the surface texture.3 It concerns the surface appearance of the objects. In general, one
can divide it into macro- and micro-textures (Fig. 10).5,16 Macro-textures are topographical
variations found on enamel surface, as, for example, the ridges and development sulci,
and are responsible for broad areas of light reflection. Micro-textures are formed by tiny
alterations of the enamel surface, occurred by deposition of hydroxyapatite crystals, car-
ried out by the ameloblasts during the formation of the tooth germ, which results in the
formation of small parallel sulci, named perikymata. A perikymata-rich surface is responsi-
ble for creating diffuse reflection areas on the tooth surface and the consequent decrease
of translucency.
Figure 10.
Figure 10. Surface texture.
78
Teeth are formed by overlapping of enamel on dentin. A primary factor when stu-
COLOR DYNAMICS IN
NATURAL TEETH
dying dental polychromatism is the variation in thickness of these tissues as a function of
physiological aging. In natural teeth, value or brightness is a enamel-related feature, while
chroma and hue characterize dentin. Young people, less exposed to wear caused by die-
tary acids and toothbrushing, have thicker enamel than elderly people, and hence lighter
teeth. As wear is enhanced and the thickness of the enamel layer decreases, the enamel
translucency increases, which allows the chroma and the hue, features related to den-
tin, become increasingly evident. Thus, during the process of interaction of light with the
dental tissues, enamel plays an important role acting as a filter, whose greater or smaller
thickness accounts for brighter or less bright teeth (Fig. 11, 12 and 13).12,44
Enamel plays an important role acting as a filter, whose greater or smaller thickness
accounts for brighter or darker teeth. Thus, in the cervical third, where enamel is thin, dentin
color is only attenuated, and the chroma is high. In the middle third, where it is thicker, ena-
mel is able to significantly filter the characteristics of dentin, making this region to present
high luminosity and low saturation.19 In the incisal third, where dentin is thin or absent, hue
and chroma of the tooth are replaced by translucency and opalescence effects, which will
be discussed below.
Figure 13.
Figure 11.Teeth with high value - Young individuals.

Figure 12. Teeth with medium value - adult individuals.
Figure 13. Teeth with low value - Elderly individuals.
79
In addition to presenting different degrees of translucency, enamel and dentin also
OPTICAL
PROPERTIES OF
TOOTH TISSUES
have different optical properties, that give teeth singular beauty, especially, the opalescen-
ce and fluorescence, respectively (Fig. 14).
The opalescence is an optical property that occurs by scattering of the shorter wa-
velengths of the visible spectrum, making objects more bluish opalescent when viewed
under reflected light, and more orange when observed under transmitted light.27 It is so
called because it was firstly observed in opal stones (Fig. 15).40 All of the tooth naturally
covered by enamel present opalescence. However, this property can be best seen in
the maxillary central incisors in the form of bluish strip, located near the incisal edge, and
named opalescent halo.15,50
Figure 14.
Reflected light Transmitted light

Figure 15.
Figure 14. Optical properties. The Figure shows three slices of mandibular central incisor (0.4 mm). In the right slice under reflected light, we can see the bluish tendency of the shade of enamel. In the
central slice it is noted that the orange shade is predominant, whereas the slice on the left is observed in low light environment, however rich in ultraviolet.
Figure 15. Opal stone.
80
In addition to forming the opalescent halo, opalescence also gives rise to other op-
tical phenomenon, named counter-opalescence, responsible for the orange appearance,
which can be observed in the region of the mammelon tip in anterior teeth (Fig. 16).42,50
It occurs when waves of greater length which are generally transmitted through enamel,
meet structures capable of reflecting them. When the light makes a reverse path across
enamel, blue wavelength remains dispersed while longer lengths are transmitted, making
dentin to appear orange. Because of its great aesthetic importance, the opalescence was
considered by some authors a chromatic dimension.55
The tooth is a translucent structure, and therefore, its observation is subject to the
influence of background contrast.25 Opalescence and counter-opalescence are also sub-
ject to this influence. Some authors found greater prominence of the opalescent halo
when the maxillary central incisors were in disocclusion (seen under the dark background
of the oral cavity). However, when they were in occlusion (seen with the mandibular in-
cisors behind) The opalescent halo became less noticeable, as opposed to the counter
opalescent characteristics, which were prominent (Fig. 17). By understanding the role and
importance of the opalescence and counter-opalescence, we noticed that enamel contri-
butes decisively in the expression of subtle variations of the hue observed in natural teeth.
Figure 16.
Figure 17.
Figure 16. Opalescence and counter-opalescence.

Figure 17. influence of background contrast on opalescence and counter-opalescence.
81
Fluorescence is a luminescent phenomenon, i.e., which causes spontaneous emis-
sion of light by a process other than heating. To better understand it, we must remembers
that the whole visible light is situated in a narrow band of the electromagnetic field, limited
at the bottom end by the ultraviolet (UV) radiation and at the top end by the infrared radia-
tion (both radiations invisible to the human eye).49
While most objects dissipate the luminous energy absorbed as heat, fluorescent
objects re-emit part of this energy in a visible, longer wavelength, and in a higher speed
10-8 segundos.
Among other luminescent phenomena we can highlight the phosphorescence.
Phosphorescent objects differ from fluorescent by the speed of reemission of light energy.
While fluorescent objects no longer display luminescence when the exposure to the ra-
diant energy ends, phosphorescent objects can continue to present this feature for more
than a day. This difference is explained when comparing the time required for the return of
molecules excited by the radiant energy to its original orbital position.46
Although there is evidence that dentin and cementum exhibit red color when under-
go the incidence of green light,24 fluorescence of the teeth is usually associated with blue-
-white color appearance, due to the impact of UV length emitted by black light commonly
found in the dance floor and in nightclubs (Fig. 18). In such an environment, the incidence
of UV length in a tooth restored with non-fluorescent material causes metameric failure,
responsible for highlighting the restorative treatment, which, unlike the blue-white tooth, is
perceived as colorless (Fig. 19).31
Fluorescence is an optical property which is present both in enamel and dentin,
however, since it has been associated with the amount of organic matter, its intensity is
three times higher in dentin than in enamel. This occurs due to the presence of colla-
gen fibers, more precisely due to amino acids which help to build these fibers, such as
tryptophan, pyrimidine and pyridinoline.21,37 Under natural light, fluorescence makes teeth
brighter and shiny, and gives them “internal luminescence”.28
Despite the fact that the fluorescence of enamel is less than the fluorescence of dentin,
its observation has been described as an effective alternative to initial diagnosis of caries due
to the low fluorescent intensity of carious enamel when compared to sound enamel.53 When
Figure 18. Natural teeth observed in low light environment, however rich in ultraviolet.
Figure 19. Tooth with non-fluorescent restoration observed in low light environment, however rich in ultraviolet.
82
human dentin was irradiated with light in the range of 365 nm with a fluorescence peak lo-
cated in 440+/-10 nm was observed.17 According to the study by Matsumoto, Kitamura &
Araki (1999), the physiological aging process increases the intensity of dental fluorescence
due to a biological and thermal mechanism which acts on dentin.29 This result is in line with
the changes of enamel resulting from physiological wear, which becomes thinner and more
translucent over time, which allows for better visualization of the underlying dentin fluores-
cence.
Although the subjectivity of the visual observation method is proven in several stu-
SHADE GUIDES
dies, to visually compare the natural tooth with artificial shade guide is still the primary
means of shade selection used in Dentistry.
The first shade guide, with 60 chromatic samples, was created by Clark in 1930.10
Since then, several studies have been performed to optimize its clinical application, but
without significant changes.35 Currently, Vitapan Classical® (VC - Vita Zahnfabrik, Bad
Säckingen, Germany) and 3D-Master Vita® (V3DM – Vita Zahnfabrik, Bad Säckingen, Ger-
many)the most popular chromatic scales are considered. From a few differences presen-
ted by these scales, the difference in the arrangement of their chromatic samples stands
out - in the first range it is performed in groups of hues, while in the second one, it takes
place in groups of value.45
Formed in 1950, the VC shade guide (Fig. 20) has gained popularity to serve as the
chromatic standard for ceramicsystemsfrom different manufacturers.7 This shade guide
has its chromatic tabs in four shades groups: A (brown), B (yellow), C (gray) and D (red).
Different degrees of saturation (chroma) can be observed for the same hue expressed by
numbers. Increasing number corresponds to increased hue saturation. Thus, the hue has
five chromatic intensities (A1, A2, A3, A3,5, A4) the hues B and C show four (B1, B2, B3
and B4; C1, C2, C3 and C4), while the hue D has only three (D2, D3 and D4).
Figure 20.
Figure 20. Vita Classical® shade guide (Vita Zahnfabrik, Bad Säkingen, Germany).
83
For decades, the VC scale was considered among a reference shade guides, although the earliest studies also have
been described problems regarding its use. Among these problems, there is inconsistency of the chromatic coverage
range, which is characterized by loss of clinical time or impossibility to obtain the ideal chromatic sample.33,39 According to
other studies, the A and B hues of this scale are present in most of natural teeth.12 The difference in shape and structure
and of the teeth and the samples and the chromatic difference between samples of the same designation in the same
brand scales are also often problems described.
The small variation among dental shades and ocular physiology (which gives greater ease to detect minor variations
of value than small variations of chroma and hue) made value the main dimension of color in Restorative Dentistry. To adapt
to this new concept, some authors have suggested that VC scale tabs to be reordered according to the value (B1, A1, D2,
A2, B2, C1, C2, D4, D3, A3, B3, A3,5, B4, C3, A4, C4).According to these authors, reordering tabs from the lighter color
to the darker color provides a monodimensional evaluation system, which favors checking the correct color, saving clinical
time and easier communication with the potter.32
The V3DM shade guide (Fig. 21), developed in 1998, presents its chromatic tabs arranged in five groups, according
to the value. According to the manufacturer, unlike its predecessor, developed empirically, this shade guide was designed
to meet modern aesthetic concepts. It features 26 chromatic tabs distributed in five groups designated by numbers (1, hi-
ghest value; 5, lowest value). Selecting value consists of the first step of its use. Then the chroma selection must be made
within the selected group value. In the groups of value 2, 3 and 4, there are three columns of chromatic tabs with the letter
M (middle), L (yellowish) and R (reddish). The selection of the chroma must be initially carried out in the column of letter M.
These letters represent the hue, the last step of shade selection. At that point the clinician should evaluate the tooth the
existence of reddish or yellowish tabs than that presented by the tab of column M.
Figure 21.
Figure 21. Vita 3D-Master® shade guide (Vita Zahnfabrik, Bad Säkingen, Germany).
84
Several studies have reported the optimal distribution of guide tabs V3DM compared
to other shade guides.36 According to these studies, this shade guide offers greater cove-
rage and uniformity of tabs’ distribution, allowing for greater precision and easier shade se-
lection.Another study, however, showed that this shade guide, although more uniform than
the others, also presents chromatic gaps and limitations. Recently, Paravina evaluated the
clinical performance of shade guides by comparing VC, V3DM and a new shade guide,
developed based on the V3DM shade guide (Vita Linear Guide 3D Master® – Vita Zahnfa-
brik, Bad Säckingen, Germany). The results showed that the new shade guide achieved
the highest efficiency, which demonstrates the continuous evolution of the shade guides
and the inconclusive nature of the subject.34
In the instrumental shade matching, the devices carry out the observation and re-
INSTRUMENT SHADE
EVALUATION
gistration of the shade mathematically, providing reliability to the method.9,13,18 This can be
achieved by the use of spectrophotometers, colorimeters and digital computer analysis.
Spectrophotometers are devices used to measure the color of an object by their
reflected wavelengths (Fig. 22). This record is obtained in the three-dimensional coordi-
nate of the CIELab system. The L* axys indicates the achromatic coordinate or brightness
of the object, with values from 0 (absolute black) to 100 (full white). The a* and b* axes
indicate the chromatic coordinates, that present the three-dimensional positioning of the
object in the color space and its direction. The a* axis is the amount of red (a* positive
value), or green (a* negative value). The b* axis is the amount of yellow (positive b * value)
or blue (negative b * value).47 When the values of a * and b * axes come closer to the zero,
representing an achromatic area based in the value scale. Currently, some spectrophoto-
meters also have capacity to evaluate tooth color according to shade guides, upon prior
calibration of the device.
Figure 22.
Figure 22. Vita Easyshade® spectrophotometer (Vita Zahnfabrik, Bad Säkingen, Germany).
85
Furthermore, colorimeters perform color evaluation from reflected wavelengths, re-
cording the results in three chromatic axes (X, Y, Z tristimulus or Cielab).22,48 Several stu-
dies in the literature about color of natural teeth were performed with this type of device,
which demonstrated reproducibility in studies performed both in vitro and in vivo.13,18 When
these comparisons are made with computerized digital imaging support, the results de-
monstrate to be promising, but inconclusive for some authors, who suggest the need for
further investigation.
The excellence of the optical properties associated to extremely conservative pre-
SHADE SELECTION FOR

CERAMIC VENEERS
parations made ceramic veneers a more popular treatment alternative. The color of treat-
ments carried out with ceramic veneers is a result of viewing the light interaction with the
ceramic veneer, with resin cement and the supporting substrate which may be formed
by dental tissue and/or restorative material. When performing planning of these restora-
tions, one must consider the primary chromatic influence of the substrate. Therefore, a big
difference between the initial color of the substrate and the desired final color is a great
restorative challenge. So it is up to the ceramic veneer and the resin cement the roles of
neutralizing the color of the substrate and determining the final color of the restoration.14,52
Ceramic veneers are manufactured with varying thicknesses, which may vary from 0.3
mm to 1.5 mm, having varying degrees of translucency. Generally, increasing the thickness
of the ceramic veneer is proportional to the decrease of translucency, which increases the
influence of the veneer and reduces the influence of the resin cement on the final chromatic
result.14 In addition to vary according to the thickness, the color of the veneers may also vary
according to the manufacturer, chemical composition, particle size and mode of fabrication.4,20
Resin cements, in turn, are available in different shades and are critical to the suc-
cess of restoration.2 Unfortunately, there are various systems of resin cements that have
different characteristics of color and translucency for their respective shade tabs. Thus, it
is strongly recommended to know the possibilities and limitations of the resin cement for
a successful aesthetic treatment.
The shade selection protocol differs according to the type of restoration to be fa-
bricated. However, the observation and identification of the characteristics and optical
effects should also be recorded. When color selection and reproduction are performed
by the same individual, the process becomes more simple, dynamic and reliable. This
happens when the restorations are fabricated with direct composite resin. For indirect res-
torations, the eyes conducting the shade selection are often not the same participating in
confection of the restoration. Therefore, the step of color communication to the laboratory
is extremely important in the aesthetic success of the restorations.
Shade guides are essential for communication of the color dimensions, It is utterly
important that the shade guide used for selecting the color in the office is the same used
by the ceramist in the laboratory. The shade guides, as described, do not provide all of the
features to be reproduced and may be used in conjunction with evaluation tools, chroma-
tic maps and a suitable photographic documentation.
86
In the chromatic maps, one should highlight the subtleties where stains and charac-
terizations should be located and designed.55 The photographic documentation generates
more information than any verbal and written description. Photographs with the shade
guide in position and different color options help in answering questions and, when viewed
in black and white, a lot of help in the correct value selection. The hue or chroma should
be recorded photographically, with a choice of three teeth of a shade guide touching the
incisal edges of the natural tooth, side by side. The central option should be alternatively
selected as the ideal, and the other two must have a chroma higher and one chroma
lower. Is it possible to also record the translucency characteristics through photographs
with moist teeth and a black background.
During the evaluation of tooth shade the following characteristics should be identified
and replicated in descending order of importance: (1) shape, (2) topography and surface
texture, (3) value, (4) translucency, (5) chroma e (6) hue.5,54 This order is based on the fact
that differences in shape, surface morphology, value and translucency may be perceived
at greater distances than those of hue and chroma. Logically, the correct reproduction
of a characteristic of a higher order of importance will not compensate for errors in the
reproduction of less relevant factors, but it will lessen the perception of small differences,
especially to untrained eyes.
87
1. Ahmad I. Three-dimensional shade analysis: perspectives of color. Part 2. Pract Proced Aesthet Dent. 2000;12(6):557-64.
REFERENCES
2. Alqahtani MQ, Aljurais RM, Alshaafi MM. The effects of different shades of resin luting cement on the color of ceramic vene-
ers. Dent Mater J. 2012;31(3):354-61.
3. Baratieri LN, Araújo JR, EM, Monteiro JR S. Composite restorations in anterior teeth: fundamentals and possibilities. New
York: Quintessence; 2005.
4. Barizon KY, Bergeron C, Vargas MA, Quian F, Cobb DS, Gratton DG, et al. Ceramic materials for porcelain veneers. Part II:
Effect of material, shade and thickness on translucency. Prosthet Dent. 2014;112(4):864-70.
5. Belli RH, Baratieri LN. Cor: fundamentos básicos. In: Baratieri LN, et al. Soluções clínicas: fundamentos e técnicas. São
José: Ponto; 2008. cap. 1, p. 25-51.
6. Billmeyer and Saltzman’s principles of color technology. 3rd ed. New York: John Wiley Sons; 2000.
7. Brewer JD, Wee A, Seghi R. Advances in color matching. Dent Clin N Am. 2004;48(2):341-58.
8. Chu SJ, Devigus A, Mieleszko AJ. Fundamentals of color: shade matching and communication in aesthetic dentistry. Chi-
cago: Quintessence; 2004.
9. Chu SJ, Tarnow DP. Digital shade analysis and verification: a case report and discussion. Pract Proced Aesthet Dent.
2001;13(2):129-36.
10. Clark EB. The Clark tooth color system. Parts 1 and 2. Dental Magazine and Oral Topics. 1933;50:139-51.
11. Comission Internationale de L’Eclairage. Colorimetry, official recommendations of the international commission on illumination.
Paris: Bureau Central de la CIE. Publication CIE No. 15 (E1.3.1); 1971.
12. Dietschi D, Ardu S, Krejci I. A new shading concept based on natural tooth color applied to direct composite restorations.
Quintessence Int. 2006;37(2):91-102.
13. Douglas RD. Precision of in vivo colorimetric assessments of teeth. J Prosthet Dent. 1997;77(5):464-70.
14. Dozic A, Tsagkari M, Khashayar G, Aboushelib M. Color management of porcelain veneers: influence of dentin and resin
cement colors. Quintessence Int. 2010;41(7):567-73.
15. Duarte Jr S. Opalescence: the key to natural aesthetics. Quintessence Dent Technol. 2007:7-20.
16. Fondriest J. Shade matching in restorative dentistry: the science and strategies. Int J Periodontics Rest Dent. 2003;23:467-
79.
17. Foreman PC. The excitation and emission spectra of fluorescence components of human dentine. Arch Oral Biol.
1980;25(10):641-7.
18. Goldstein GR, Schmit GW. Repeatability of a specially designed intraoral colorimeter. J Prosthet Dent. 1993;69(16):616-9.
19. Hasegawa A, Ikeda I, Kavaguchi S. Color and translucency of natural central incisors. J Prosthet Dent. 2000;83(4):418-23.
20. Heffernan MJ, Aquilini SA, Diaz-Harnold AM, Haselton DR, Stanford CM, Vargas MA. Relative translucency of six all-ceramic
systems: core and veneer materials. J Prosthet Dent. 2002;88(1):10-5.
21. Hoerman KC, Mancewicz SA. Fluorometric demonstration of tryotophane in dentin and bone protein. J Dent Res.
1964;43:276-80.
22. Johnston WM, Kao EC. Assessment of appearance match by visual observation and clinical colorimetry. J Dent Res.
1989;68(5):819-22.
23. Kim SH, Lee, YK Lim BS, Rhee SH, Yang YC. Metameric effect between dental porcelain and porcelain repairing resin
composite. Dent Mater. 2007;23(3):374-9.
24. Kvaal S, Solheim T. Fluorescence from dentin and cementum in human mandibular second premolars and its relation to age.
Scand J Dent Res. 1989;97(2):131-8.
25. Lee YK, Lim BS, Kim CW. Difference in the colour and colour change in dental resin composites by the background. J Oral
Rehabil. 2005;32(2):227-33.
26. Lee YK, Powers, JM. Metameric effect between resin composite and dentin. Dent Mater. 2005;21(10):971-6.
27. Lee YK, Yu B. Measurement of opalescence of tooth enamel. J Dent. 2007;35(8):690-4.
28. Magne P, Belser U. Bonded porcelain restorations in anterior dentition: a biomimetic approach. Chicago: Quintessence;
2003.
29. Matsumoto H, Kitamura S, Araki T. Autofluorescence in human dentine in relation to age, tooth type and temperature mea-
sured by nanosecond time-resolved fluorescence microscopy. Arch Oral Biol. 1999;44(4):309-18.
30. Melo TS, Kano P, Araújo JR E. Avaliação cromática em odontologia restauradora. Parte 1: O mundo das cores. Clín – Int J
Braz Dent. 2005;1(2):96-105.
31. Miller MB. Composite resin fluorescence. J Esthet Restor Dent. 2004;16:335.
32. O’Brien WJ, Groh CL, Boenke KM. One-dimensional color order systems for dental shade guides. Dent Mater. 1989;5(6):371-
4.
33. Paravina RD. Color in dentistry: match me, match me not. J Esthet Restor Dent. 2009;21(2):133-9.
34. Paravina RD. Performance assessment of dental shade guides. J Dent. 2009;(1): e15-20.
35. Paravina RD, Powers JM. Aesthetic color training in dentistry. St. Louis: Elsevier/Mosby; 2004.
36. Paravina RD, Powers JM, Fay RM. Color comparison of two shade guides. Int J Prosthod. 2002;15(1):73-8.
37. Perry A, Biel M. Comparative study of the native fluorescence of human dentin and bovine skin collagen. Arch of Oral Biol.
1969;14(10):1193-211.
38. Pincus CL. Building mouth personality. A paper presented at California State Dental Association; 1937. San Jose, California.
39. Preston JD. Current status of shade selection and color matching. Quintessence Int. 1985;16(1):47-58.
40. Primus CM, Chu CCY, Shelby JE, Buldrini E, Helcle CE. Opalescence of dental porcelains enamels. Quintessence Int.
2002;33(6):439-49.
41. Schmeling M. Como evitar falhas metaméricas nos procedimentos restauradores. Clín - Int J Braz Dent. 2010;17:8-10.
42. Schmeling M, Maia HP, Baratieri LN. Opalescence of bleached teeth. J Dent. 2012;(1):e35-39.
43. Schmeling M, de Andrada MAC, Maia HP, Araújo EM. Translucency of value resin composites used to replace enamel in
stratified composite restoration techniques. J Esthet Restor Dent. 2012;24(1):53-8.
88
44. Schmeling M, Meyer-Filho A, de Andrada MAC, Baratieri LN. Chromatic influence of value resin composites. Oper Dent.
2010;35(1):45-9.
45. Schmeling M, Sartori N, Monteiro Jr. S, Baratieri LN. Color stability of shade guides after autoclave sterilization. Int J Perio-
dontics Restorative Dent. 2014;34:689-93.
46. Schmeling M, Sartori N, Perucchi LD, Baratieri LN. Fluorescence of natural teeth and direct resin composite restoration:
seeking the blue aesthetics. Am J Dent. 2013;3:100-11.
47. Schmeling M, Vieira LCC, Maia HP, Lopes GC. Resinas compostas para esmalte clareado podem diminuir a luminosidade
do substrato nas técnicas restauradoras estratificadas. Clín – Int J Braz Dent. 2010;6(1)78-85.
48. Seghi RR, Johnston WM, O’Brien WJ. Performance assessment of colorimetric devices on dental porcelains. J Dent Res.
1989;68(12):1755-9.
49. Sensi LG, Marson FB, Hawerroth T, Baratieri LN, Monteiro S. Fluorescence of composite resins: clinical considerations.
Quintessence Dent Technol. 2006;29:43-53.
50. Sensi LG, Araújo FO, Marson F, Monteiro Jr S. Reprodoucing opalecent and counter-opalescent effects with direct resin
composites. Quintessence Dent Technol. 2007;4:47-50.
51. Sproull RC. Color matching in dentistry. Part 1: The three-dimensional nature of color. J Prosthet Dent. 1973;29(4):416-24.
52. Stevenson B, Ibbetson R. The effect of the substructure on the colour of samples/restorations veneered with ceramic: a
literature review. J Dent. 2010;38(5):361-8.
53. Sundstrom F, Frederiksson K, Montan S, Hafström-Bjorkmanu, Strom J. Laser-induced fluorescence from sound and carious
tooth substance: spectroscopic studies. Swed Dent J. 1985;9(2):71-80.
54. Terry DA, Geller W, Tric O, Anderson MJ, Tourville M, Kobashigawa A. Anatomical form defines the color: function, form and
aesthetics. Pract Proced Aesthet Dent. 2002;14(1):59-67.
55. Vanini L, Mangani FM. Determination and communication of color using the five color dimensions of teeth. Pract Proced
Aesthet Dent. 2001;13(1):19-26.
89
chapter 4
aesthetic rehabilitation planning
Paula de Carvalho Cardoso | Rafael de Almeida Decurcio | Ana Paula Magalhães | Marcus Vinícius Perillo
Contemporary Restorative Dentistry has an increased demanded for, comprehensive
results, and not for the individualized treatment of dental elements. Whether by general
information, or by social imposition, patients aim both aesthetically pleasing and natural
as well as physiological and mechanically sound results. Assuming a leading role, blea-
ching therapy, adhesion processes and restorations with ceramic veneers have opened the
door to a variety of dental treatments that improve appearance, usually by reversing signs
of aging and offering predictability and longevity for aesthetic and functional rehabilitation.
Understanding the expectations of patients is critical in order for the dentist to develop a
treatment plan that is not only healthy for the dental tissues but also aesthetically satis-
fying. Generally, patients may not be able to identify their needs in more than a few words,
in which their main complaints are stated. Thus, the clinician should decide when these
expectations can be met.3 The procedures described below are tools to guide the dentist
when planning that aims to achieve accurate and predictable results for Operative Dentistry
and Rehabilitation.
AESTHETIC REHABILITATION
PLANNING
With the advent of digital photography the dentist has acquired a new method for
communicating with the patient which includes images to demonstrate all of the conditions
diagnosed, immediately after obtaining them. In addition, with the incorporation of these
images became possible treatment options also to further show what has just been explai-
ned and perhaps even exemplified with cases of other patients may be used.19 Now, in a
few minutes, is possible to show, in the photo of the patient, for example, a preview of the
tooth bleaching results, lengthening or shortening the teeth, to demonstrate the possible
results that would be obtained with orthodontics or ceramic veneers.8
Recently, digital planning has become an important tool to introduce the patients to
all of the treatment possibilities that may be carried out based on ones initial conditions.
The expertise of facial and dental aesthetic principles and digital technology tools, like
Power Point® software (Microsoft Office, Microsoft, USA) and Keynote® (Apple Inc., USA),
allow for the planning of the possible treatments with predictability and security, as well as
communicating in advance with the patient and the dental lab about the possibilities.8 (Fig.
1). A complete analysis of the patient’s function as well as their subjective expectations is
most important in addition to the aesthetic planning.5
For proper rehabilitation, the aesthetic planning it is necessary to integrate aesthetic
concepts, in order to obtain harmony between ones facial aesthetics and dentofacial
composition which include the lips and smile, with their dental composition, which relates
more specifically to the size, shape and position of ones teeth and their relationship with
the bone alveolar as well as gingival tissue.5 The details to be observed during these
analysis were presented in Chapter 2 of this book, and here will be analyzed using the
photographs obtained.
92
Figure 1.
Figure 1. Digital resources available to perform the digital aesthetic rehabilitation planning. It is possible to develop digital analysis of the work (Keynote, Apple, USA) and obtain important data to the
development of the treatment. In this photo, for example, it is clear that the digital planning smile only is valid for the length and width of the central incisors (green), because they are bidimensionally
positioned facing the viewer. For all remaining teeth (lateral incisors and canines - dotted lines), the trace is valid/functional for length, however for width is simply a graphic complement, null, given the
rotation of these teeth in the arch, which prevents the accuracy of the digital demonstration.
The modern world is heading towards speed and convenience, people are seeking
PHOTOGRAPHY IN
DENTAL CLINICS
as much information in the shortest time. In this context, images have a key role, for car-
rying valuable information and without the need of words, transmitting them jointly with
emotions and desires. A well taken image or photograph may add a more deep reflection
and be able to persuade faster than words, by eliminating an unnecessary verbal analysis.
Photography is not only used for professional documentation and legal security, it has
become an indispensable tool in Cosmetic Dentistry by offering images that capture a
patient’s instantaneous emotion and further help the patient to make a decision.22
Allied to clinical and radiographic examination and study models, facial, dento-labial
and intraoral photographs are used as an auxiliary in diagnosis, and essential in achieving
an individualized aesthetic treatment planning with several specialties, integrating form,
function and biology. Photographic images, with a static character, allows for a more de-
tailed analysis of the face and smile, and, through further magnification, which are impos-
sible to be seen with naked eye. Thus, it is also an excellent means of communication
with the patient and the dental lab, and provides data such as integration of the face, lips,
gingiva and teeth, as well as information regarding the shape, shade (guides), contour and
function. All of which allows for the most beautifully executed of restorative jobs with less
possibility of repetition. In addition, the photographic record facilitates the “before/after”
comparison and the making of scientific panels, articles and classes, as well as docu-
mentation of procedures, materials and prosthetic parts as well as the close observation
of natural teeth.12, 20, 22, 24, 27
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DIGITAL PHOTOGRAPHY
Although this technology have had its origins in the 1970s and the first digital ca-
mera was introduced into the market in the 1990s, the clinical use of this tool within the
dental office only became a reality in the early twenty-first century.15 The possibility of the
immediate display of a photograph, the elimination of film costs as well as developing and
the systematization of the management of the images within the clinic are some of the
advantages over the analogical system.15,17
We can conceptualize photography as the process of obtaining an image from the
light captured by an objective lens (commonly known as a lens, but actually formed by a
set of lenses). In digital photography, the photons (“particles” of energy) of light promote an
electronic response onto a digital sensor (CCD – charge-coupled device), located within
the camera body. These electrical signals are then recorded in bits in a memory card and
may be stored and manipulated with computers.8,29 (Fig. 2)
Learning to shoot, in short, means understanding and mastering the art of capturing
and processing light.14 Three features of the light input should be balanced within the ob-
jective in order to record “faithful” images: quantity, time and sensitivity.8,26 The relationship
between these three elements, ie the period during which an amount of light will reach a
sensor with a predetermined sensitivity, is called exposition.26
The amount of light is determined by the diaphragm, a series of metal blades located
inside the objective and controlled by commands from the camera body. These blades
form a central orifice of adjustable opening through which the light which will reach the
sensor passes. The aperture diameter is expressed in numerical fractions, conventionally
known as f number. Since the number f is a fraction, the lower the f-number, the greater
the aperture: a f/2.8 aperture has a much greater diameter and enables a greater amount
of light to capture than a f/22 aperture.8,21,29
Diaphragm Shutter
Sensor
ISO
Figure 2.
Figure 2. Scheme with the operation of a digital camera and parts thereof.
94
When using large openings (e.g., f / 1.8 or f / 2.8), images are produced with lower field depth, ie a small area of the
photograph will be well “focused” or quite clear, and everything that is ahead or behind that zone will be “blurred”, fogged.
Small field depths are widely used in outdoor portraits because the “blur” of the irrelevant part highlights the selected object,
but highly undesirable for dental photography, since we need to obtain images punctually highlighted in a framework in
which all of the elements are relevant.8,21
As we decrease the aperture (increasing the f-number), we obtain a greater depth of field. Intermediary aperture
values (f/8 to f/13) are of interest for landscape photography, where the sharpness provided by the aperture is distributed
allowing for the photographed objects to be visible; however, if seen at higher magnifications, they do not have sharpness.
Extremely small apertures (f/22 to f/32) are desirable for clinical photography, so that we can highlight and clearly observe
both the anterior and the posterior teeth, as well as other structures involved. (Fig. 3a-d) For the carrying out of the facial
photographs, medium apertures (f/11 to f/13) produce a sufficient field depth.8,21
The time of exposure of the sensor to the light is determined by the shutter, a mechanical device located inside the
camera body, facing the digital sensor. The shutter works as a window that remains opened for a fixed interval allowing for
the sensor to be reached by the light passing through the objective lens. Time can be expressed in seconds (1”, 5”, 30”)
or fractions of a second (1/x: for example, x equal to 100 is 1/100 or a hundredth of a second). The shorter the exposure
time, the less ammount of light will hit the sensor. In practice this means that, if all other variables are kept constant, the
shorter the exposure time, the darker the image.8,21,29
Figure 3. Photographs with ideal settings of depth of field (high f-stop) allow for static and careful analysis of all components involved in the picture (f/22, 1/125, ISO 100). Importantly, the higher the
f-stop,the higher the sharpness of the picture components that are distant from the central point of focus, that is, the depth of field increases. However, for this more flash power is required (a-b). Photos
with inadequate defaults for depth of field (low f-stop) make it impossible to analyze all components involved in the picture around the central point of focus, due to the apparent loss of sharpness as it
moves away from the main focus (f/8, 1/125, ISO 100). (c-d)
95
Because aperture openings required for clinical photography are very small, it is necessary that the light be captured
for an extended period of time to obtain an image with balanced exposure, but during this period both the movement
(shaking) of the photographer and the patient would be recorded on the image. For this and other reasons discussed
below, it is necessary to use an additional light source, the flash, which has the function to add light to the photographic
environment, so that it is possible to use small aperture openings over quite small intervals as well. The recommended time
interval for dental photography is 1/125s.8,21 (Fig. 4a and 4b)
The sensitivity of the sensor is determined by the ISO, expressed in numerical values, usually from 100 to 3200. The
smaller the value, the less sensitive the sensor, and the less light it records, but on the other hand, sharper images are
produced. As higher ISO values are used, it is possible to observe something called noise, like millions of tiny colored dots
had stipled the entire image. (Fig. 5a and 5b) Higher ISO values are used under low light; for example, in dark environments
or at night, without the use of a flash. In Dentistry, the ISO number used must be as low as possible (100 to 200), in order
to produce the lowest noise level. Because the aperture used will be very small, this is only possible to the use of flash.8,21,29
Figure 4. Photographs of the same scenario with different shutter speeds and, consequently, different amount of light. The image shows the result of shot photographic setting with 1/8 second speed.
Thus, it is possible to observe with certain clarity the objects in the picture without major distortions because the of light speed entering the capture sensor is high and produces a sharper image with
respect to the components of the whole image ensemble (a). The image presents the results of a photo taken with a 1 second shutter speed. It is therefore not possible to clearly observe the objects
in the image captured by the sensor due to the slow speed of aperture and closure of the shutter, which generates a distorted image of the components throughout the image with the visual sensation
their movement. (b)
Figure 5. Photographs of the same scenario with different ISO. The image was captured with a high ISO value (12,800), which promoted excessive image noise or blur (layman term) of the object.
This situation is explained due to the adjustment of the ISO electronic sensor for high light sensitivityand indicated to capture photos in low light without the flash support. Considering that the images
captured for Dentistry are obtained with flash, low ISO values are recommended, to not create noise (sharpness of detail). (a) The image was captured with a low ISO value (100), which allowed minimal
image noise (high sharpness of detail). So, by analogy, it is concluded that dental photographs must be taken with the lowest ISO values, because is always used flash, and it is not necessary to
sensitize the electronic sensor (ISO) to capture light emitted by the objects of interest. Thus, important details are kept. (b)
96
Another important feature of photography is the white balance (WB), defined simplistically as the color reading per-
formed by the camera. This reading may be automatic or manual. When the white balance is automatic, with the variation
of ambient light, there may be a variation with respect to how the camera interprets and records the colors. For obtaining
images with the same color pattern, and for this pattern to be as close to natural as possible, it is suggested to use the
white balance always in the “flash” or “daylight” mode or set at 5,600 K.21,29 WB adjustment differences occur due to dif-
ferences in factory settings of the equipment as well as the building of light-capturing sensors. If the WB is not configured
correctly, images may become “warmer” or yellowish. Ideally, the optimal adjustment is in the Kelvin mode (5,600 ºK), which
is the most faithful to the color, however in cameras that do not have this WB module this difference may be compensated
for by working on the adjustment of its chromatic map. This, in turn, compensates for the color reading by increasing or
decreasing its temperature, from blue to yellow, or from red to green. (Fig. 6a-h)
Figure 6g. Figure 6h.
Figure 6. WB K5600: ideal for dental photograph protocols of the mouth and face, this color temperature (or White Balance) equivalent to sunny daylight of midday, the most faithful to observe the color
of teeth and other adjacent tissues. This is because invariably we use flash for dental photographs, which is equivalent to daylight. The other adjustments of White Balance will always produce distortion
of the captured image due to the generation of average color temperatures, because we use dental flash in combination with the proposed adjustment. (a)
WB Shade: lower color temperature control, tending yellowing the photos, when used with dental flash. (b)
WB Cloudy: higher temperature setting, close to 9,600 tending to bluish the picture, because this considers as “cloudy” (gray environment, dim lighting) and corrects the ambient color in the final result
of the photo. However, when using flash, the settings conflict and form a gently yellowish image.(c)
WB Flash: specific regulation for the use of flashes. However, there are color variations depending on the manufacturer. For Nikon® equipment, Dental photographs can be made in WB mode; however,
in Canon® equipment in the same setting the photos tend to become yellowish. (d)
WB Daylight: nearest setting of the ideal temperature of 5,600 K, when the equipment does not have WB adjustment in Kelvin, ideal option is setting “Daylight” at 5200 K. For Canon® equipment, lacking
the setting in Kelvin, this setting is ideal. In this image, the homogeneity is observed with the caption DEN 1920 image, because they were shot by Nikon® equipment. (e)
WB Fluorescent: When in this mode, coupled with a flash, color temperature conflict results in a bluish picture. (f)
WB Incandescent: When in this mode, coupled with a flash, the color conflict between yellow (incandescent) and “white” flash results in a greenish image. (g)
WB Automatic: when used with flash, the final temperature is close to the “Flash” mode. (h)
97
EQUIPMENT CHOICE FOR CLINICAL DENTAL PHOTOGRAPHY
The ideal camera body for Dentistry is called the Digital Single Lens Reflex (DSLR),
which allows an interchangeable objective. In compact cameras, lens and body are
joined, forming a single structure. (Fig. 7a) Despite their ease of use and the affordable
price, their use is limited to professional use, since this type of camera does not allow for
the use of other objectives or external flashes, besides presenting limitations related to the
specific settings for Dentistry. There are many different DSLR camera bodies available on
the market, and there are frequently releases.8,21,29 The difference between the cheapest
and the most expensive professional equipment are primarily the technological resources
applied to image-capture sensors, as well as functions that make life easier for the opera-
tor, such as picture -by-picture cropping, color adjustments, contrast, saturation, bright-
ness, texture and sharpness, features that were once only made possible through the use
of a personal computer, after downloading the images. Moreover, the body of equipment
is generally more resistant. DSLR equipment have at least 18 megapixels, this resolution
is more than adequate for dental photographs. (Fig. 7b)
The most important aspect applicable to the choice of equipment for clinical dental
photographs are the choices of the objective and the flash. Image quality is defined by the
quality of the objective and the quality of the image capturing sensor. The more expensive
the body of the machine, the better are their sensors. In this case, it is desirable to obtain
reliable images without distortion, of the photographed subjects: teeth, gingiva, lips and
face. This is only possible with lenses that have a focal length above 90 mm. Focal length
is the distance between the point of light convergence in the first lens on the objective
entry, to the image capturing sensor. Lenses with a normal to wide focal length (10 mm to
55 mm respectively) usually cause distortion of the photographed subject.
It also should be considered that the teeth are small objects, which will be photo-
graphed at short distance, what is merely allowed when using macro type lenses. Macro
lenses enable an upclose approach to objects, similarly to a magnifying glass, without
preventing long distance shooting. The 100 mm and 105 mm macro lenses, sold by Ca-
non® (Japan) and by Nikon® (Japan) respectively, are the most suitable for both intraoral
photographs (teeth) and extraoral (smile and face).8,13,19,20,23,30 (Fig. 8a and 8b)
The most suitable flash model is a special flash for macro photography. It is tailored
at the tip of the lens, located right next to the photographed subject, and because it has
at least two light sources (ringflash or punctual) there is little or no shade formation4,8,17 as
well as creating a minimum amount of texture and volume. The twin flash or bipunctual is
the most difficult to handle, although it can provide greater capture of details, texture and
volume, especially if diffusers are used. Rapid and growing technological advancement
has made this equipment increasingly affordable.21,29 (Fig. 9a-d)
Among the various shooting modes, clinical dental photography is one of the most
practical and direct, requiring nearly standardized specific equipment and techniques for
performing shots.7,10 Thinking about it, the EyeSpecial® II photographic equipment (Shofu,
Japan), released in 2014, combines a great majority of DSLR characteristics with the
advantages of a compact machine, which facilitates the capture of professional quality
images similar to those obtained with Reflex equipment. (Fig. 7c)With intuitive concept
98
and pre-programmed shooting modes as well as being defined by an image type of in-
terest, this equipment demystifies clinical photography, facilitates capturing and dental
records, and maintains the high standard of image quality required for the development of
appropriate rehabilitation planning, ie is an excellent alternative for professionals who do
not intend at scientific and didactical production of materials generated by professional
cameras. The structuring of a clinical protocol of photographs to be obtained enables
allow for systematic organization of the dentist, which facilitates as much the photographic
techniques as well as the storage and use of the images.
Figure 8a. Figure 8b. Figure 9a.
Figure 9b. Figure 9c. Figure 9d.
Figure 7. Different cameras found on the market: compact machine, not indicated for use in Dentistry (a); DSLR type professional machine, most suitable model for use in practice (b); and EyeSpecial® II
equipment (Shofu, Japan), for specific use in clinical photography (c).
Figure 8. 100mm (Canon®) e 105mm (Nikon®) macro lenses, which can be adapted to DSLR machines for clinical photograph.
Figure 9. Flashes for macro photography available for dental photography: ringflash (a-b) and twin (c-d).
99
PHOTOGRAPHIC PROTOCOL FOR DENTISTRY (Fig. 10)
Figure 10.
Figure 10. Set (minimum) of pictures that compose the photographic protocol recommended by the authors of this book.
100
First, it is important to ensure the quality of photographs taken not only by photogra-
phic techniques, but taking care of what should or should not be captured in the images.
Preferably, the patient should not be with adornments or ornaments that take the viewer’s
attention, such as necklaces, earrings, hairstyles or strong colored lipsticks. In the case of
long hair, it must be bound with elastic or thrown behind the shoulders.
Every tooth must display little or no saliva and should be free of other effects that pro-
duce distraction. Procedures such as impressioning, occlusal adjustment and others whi-
ch may leave residues or marks on the teeth or skin of patients should be performed after
shooting, because the captured image probably will be compromised by the presence of
impression material residues, labial and facial marks caused by modeling, dehydration of
the teeth, etc. In the case of inflamed and/or infected gingival tissues, as well as the pre-
sence of extrinsic stains, plaque and calculus, images should be obtained after the patient
undergoes the basic therapies of oral hygiene and oral adequation through the control of
inflammatory processes, except in cases where the capture of the images of these clinical
conditions is relevant.17,18,21,26
The choice of the photographs to be made in the photographic protocol is the den-
tist’s responsibility. The basic recommended protocol comprises facial shots with labial
sealing, facial with lips at rest, facial of the smile, dento-labial with lips at rest, frontal and
lateral of the smile, intraoral in occlusion (frontal and lateral), upper and lower of the oc-
clusal with mirror, anterior teeth with black background and photos with a shade guide. It
is interesting to adopt standardized shots and adjustments of equipment, to facilitate and
enable future comparisons. 17,18,19,21 (Table 1)
Table 1. Equipment settings and accessories needed for each of the involved photographs in the photographic protocol.
PHOTOGRAPHS ACCESSORIES MACHINE SETTINGS

FACIAL Frontal: lip seal, lips at black contrast Aperture: f/11 to f/13
rest, smile
Speed: 1/125
Profile: lip seal, lips at
ISO: 100 to 200
rest, smile
. . . White Balance WB: Flash (Nikon®), daylight(Canon®)
. . . or Kelvin (K) 5,600
Flash output: 1/2 or 1/4 in manual mode
DENTO-LABIAL Frontal: lips at rest, smile none Aperture: f/22 to f/32
. Profile: smile . Speed: 1/125
. .
ISO: 100 to 200
INTRAORAL occlusion frontal, “C” and/or “V” shaped lip retractors,
occlusion lateral, maxillary White Balance WB: Flash (Nikon®), daylight(Canon®)
. with black contrast.
teeth, black contrast or Kelvin (K) 5,600
. .
smile, with retractor and Flash output: 1/2 or 1/4 in manual mode
SHADE GUIDE “C” shaped lip retractors,
. black contrast black contrast, shade guide .
. . .
OCCLUSAL occlusal maxilla, occlusal “C” shaped lip retractors, Aperture: f/14 a f/16
mandible occlusal mirror
Speed: 1/125
ISO: 100 to 200
White Balance WB: Flash (Nikon®), daylight(Canon®)
or Kelvin (K) 5,600
Flash output: 1/2 or 1/4 in manual mode
101
The manufacture of a simple photographic protocol for Dentistry includes accesso-
ries like:
1. professional digital camera equipment and accessories (eg a Nikon D600® came-
ra, AF-S Micro NIKKOR® 105mm f/2.8 lenses and Nikon SB-R200® twin flashes
(Fig. 11a);
2. mouth openers (eg “C” and “V”shaped adult lip and cheek retractors) (Fig. 11b-d);
3. set of contrasts for photography (eg Flexipalette®, Smile Line, Switzerland) (Fig.
11e-g);
4. mirror set (e.g., crystal or metallic mirrors) (Fig. 11h); and
5. Basic kit for performing the prophylaxis and removal of extrinsic stains.13; 21;28
Figure 11. Accessories used in the preparation of the photographic protocol: (a) Professional digital camera and accessory equipment; (b) “C” and “V” shaped adult mouth props; (c) set of contrasts for
photo (Flexipalette®, Smile Line, Switzerland); and (d) set of metallic mirrors.
102
The first pictures to be made in the photographic protocol are extraoral photographs,
EXTRAORAL PHOTOGRAPHS
since the retractors and mirrors required for intraoral photographs may leave marks on the
patient’s skin and compromise the quality of the extraoral images to be obtained. there
are two main types of extraoral photos: facial, close-up of the lower face, or dentolabial.
PHOTOS OF THE FACE

For facial photos, values should be set from 11 to 13, the exposure time should be
set at 125 (1/125 second), and ISO (sensitivity of the light sensor), between 100 and 200,
for less noise. The white balance should be adjusted to the flash or day-light mode or the
5,600 ºK option. The flash light must be set in “manual” mode and power ½, but it may
also be modified using bouncers and diffusers.19,21,28,29 Framing should include head, neck
and part of the patient’s chest, not extending too much to the cervical region.17
FRONTAL FACIAL
Frontal images must be obtained with the patientin the prone position , with the ca-
mera located perpendicularly to the patient nose level, to facilitate and standardize obtai-
ning a constant vertical angle during the “before” and “after” photos. A predictable manner
to avoid distortions is to position both the patient and photographer standing or sitting, ide-
ally on the same horizontal plane. The patient’s head must be positioned so that their nose
is placed at the center, the interpupillary line is parallel to the horizontal plane to prevent
vertical tilting, and the Frankfurt plane is as parallel as possible to the horizontal plane, to
avoid horizontal tiltings and consequent analysis of distortions. The picture’s background
should be neutral and uniformly colored.
Within these images, along with the facial midline (vertical), some horizontal lines are
drawn in order for a patient’s facial analysis from the definition of the thirds of the face to
be made by observing the following features:
• hair line (horizontal);
• eyebrow line (horizontal);
• interalar line (horizontal); and
• mentus base line (horizontal).
Frontal images of the patient’s face at different positions must be obtained for a more
comprehensive analysis of the face - with labial sealing, lips at rest and smile.
a) Face with labial sealing (Fig. 10a).

In this initial facial image, the patient should be position with sealed lips.
b) Face with lips at rest (Fig. 10b and 12).
The photo should display the patient’s face with lips slightly parted in a resting position.
c) Smiling face (Fig. 10c).
The image of a the patient exhibiting a natural smile without the mouth open as in
“laughter” and without the lips being stretched or distorted. This shot must be taken qui-
ckly at the very moment the patient cracks a smile, because a very few people are able
to maintain the lips in position for more than a few seconds. Nevertheless, a number of
images of the smile should be optimally taken, because it is possible to capture it at diffe-
103
rent degrees, each photo contains valuable information for the aesthetic planning, making
it possible to select the captured images.
In this photo, the use of a digital facial bow is recommended as a standard for analy-
sis and aesthetic reference, which is composed by the following lines (Fig. 13):
• facial midline;
• lines of the nose wing; and
• line of the incisal edge.
Some horizontal lines which were already been discussed in Chapter 2 of this book
can also be traced in the same photo. The literature is unanimous on the importance of
the parallelism between these horizontal lines of the face for harmony and aesthetics, and
they must also be perpendicular to the midline.3,5,11
These lines are:
• interpupillary line: passing through the center of the pupils in both eyes;
• eyebrow line: passing over the eyebrows;
• line of the labial commissures: touches the corners of the lip on both sides;
• occlusal plane: tangent to the incisal edges;
• line of the incisal edge: contours the incisal of the six anterior teeth; and
• mentus line: tangent to the base of mentus. (Fig. 14)
Figure 12. Figure 13. Figure 14.
Figure 12. Parallelism between the horizontal lines of the face, which must also be perpendicular to the centerline, and aesthetic harmony are observed.
Figure 13. It is observed that the nose wing lines are tangent to middle third of the labial surface of the premolar and reveal that the canines need labial volume for establishing an ideal condition, which
is the tangency of the nose wing line in the distal portion of the maxillary canines, revealing an ideal relationship of width of the six anterior superior teeth in the smile. Detail for parallelism found between
the line of the incisal edge and the curvature of the lower lip.
Figure 14. Digital bow established with the tracings of the interpupillary line, eyebrow line, line of the lip commissures and the occlusal plane: tangent to the incisal edges; line of the incisal edge: incisal
contour of the six anterior teeth and chin line.
104
PROFILE OF THE FACE (Fig. 10d-f)
Identical references taken from the frontal aspect are then taken of the patient’s profi-
le, from both the right and the left side: labial sealing, lips at rest and the smile. It is impor-
tant to note that the patient must be totally to the side, which provides a superio contour
of the face. There should not be any vertical or horizontal tilting of the patient’s head and
the previously mentioned reference position must be observed.
In the profile picture of the patient, three points are defined: glabella, subnasal and
pogonion. The angle formed by the union of these three points will define the patient’s
profile as normal, convex and/or concave.5,11 (Fig. 15a)
Other profile references are used to evaluate the harmony of the face and its conse-
quences, such as:
• Line E: connects the tip of the nose to the mentus tip; (Fig. 15b)
• nasolabial angle; and (Fig. 15c)
• true vertical line: a perfectly vertical line drawn approaching the patient’s face from
profile until touching the nasolabial angle and, ideally, it is observed that the nose
should be 8 mm to 10 mm beyond, the upper lip, 2 mm to 5 mm, the lower lip from
0 to 3 mm, and the pogonion must be up to 4 mm. (Fig. 15d)
Both line E as well as the nasiolabial angle may be significantly changed after pros-
thetic treatment.
Figure 15a. Figure 15b. Figure 15c. Figure 15d.
Figure 15. Convex profile. Class II, or convex profile patient with low dominance of the central incisors by the incisal (a). Analyzing line E, the upper and lower lips are below the line, which imparts an
aspect of normal profile (b). Nasolabial angle greater than 95º and in disagreement with the ideal reference for men (c). Analyzing the true vertical line, it is observed that the upper lip does not exceed the
referred line ideally 2.0 mm at the very least. This discrepancy is coincident with the discrepancy of the nasolabial angle, suggesting lingual inclination or absence of tooth volume of the maxillary teeth. (d)
105
DENTOLABIAL
For this group of photos higher values should be set, between 22 and 32, and the
exposure time, as well as the ISO number for the the same facial shots are used (1/125
second and 100/200, respectively). The white balance will also be adjusted to flash, dayli-
ght or the 5,600 ºK position.The flash output this moment may be from ½ to ¼ within the
“manual” mode.19,21,28,29 The framing should include the base portion of the nose, cheeks
and chin, and the entire patient’s mouth. The center of this image varies according to the
different patient positions.
a) Lips at Rest (Fig. 10g)

The photo at rest is aimed to evaluate the degree of dental exposure with the lips at
rest, especially the maxillary central incisors, which should show the lips slightly parted,
and the upper lip philtrum should be at the center of the picture. (Fig. 16)
b) Full Frontal Smile (Fig. 10h)

The photo should show full smile, the lips with a naturally broad smile, without the
mouth being open as if “laughing” and without the lips being stretched or twisted. As with
the facial shot, this should be done briefly and repeatedly, seeking to capture the most na-
tural and spontaneous smile of the patient. Still, the upper lip philtrum must be positioned
in the center of the photograph, and the incisal plane of the maxillary teeth (aligned parallel
to the interpupillary line) should be horizontally positioned in the center of the image. If there
is any discrepancy of the midline, inclination of the smile or of the incisal plane, evident
within the full facial view, then this identical asymmetry should be reproduced. (Fig. 17)
In this photo, the analysis of the following aesthetic features may be carried out:
• the smile line;
• buccal corridor;
• the incisal curvature; and
• curve of the lower lip.
c) Full Lateral Smile (Fig. 10i)

With the same characteristics mentioned for obtaining the image of the full frontal
smile, the photograph of the full lateral smile has the same vertical angle as the frontal
photos, though obtained laterally, with the maxillary lateral incisor centrally positioned in the
photograph, being possible to view the central incisors and the opposite lateral. In cases
where the width of the smile is important, the opposing canines are also visible. This pho-
tograph should be taken from both sides of the patient’s mouth.
In this image, it is possible to laterally evaluate the same conditions described for the
frontal shot of tooth/lips.
106
Figure 16. The photo at rest shows the ideal tooth exposure for men on average 1.9 mm.
Figure 17. Detail for the parallelism of the line of the incisal edge and the line of the lower lip curvature, showing a condition of normality.
The intraoral photographs are taken with the same settings used for those of the
INTRAORAL PHOTOGRAPHS
lower face: f/22 to f/32 aperture, 1/125 second speed, ISO 100 or 200, white balance
set to flash, day-light or 5,600 ºK, and the flash output set from ½ to ¼ in the “manual”
mode.20,21,28,29
a) Intraoral in Frontal Occlusion (Fig. 10j)

This image should be obtained with lip retractors for the full visibility of the gingiva of
all the teeth. It can be taken in prone or frontal position of the patient, standing or sitting,
similar to the previous shots or behind them. For the last option, the patient should be lying
down enabling the photo axis to be perpendicular to the subject, with the median sagittal
plane parallel to the vertical, and the occlusal plane parallel to the horizontal borders of
photograph.
b) Lateral Photo of the Maxillary and Mandibular Teeth (Fig. 10k)

The maxillary and mandibular teeth should be occluded. The maximum amount of
gingiva should be visible, as seen in the photo of the lips with the retractor. The maxillary
lateral incisor should be the center of the image as well as the opposite central incisor
should be visible. In cases where arch width is of significant importance, the opposite late-
ral incisor and canine appear in the picture obtained. Repeat the protocol on the opposite
side.
c) Maxillary Teeth with Contrast for Photography (Fig. 10l)

Similar to the intraoral technique with frontal occlusion, this technique should be per-
formed with lip retractors, providing gingival visibility for all of the maxillary teeth, and may be
carried out in the frontal position to the patient or behind them. Differently from the previous
one, in this shot contrast for photograph, a black background, should be placed between
both arches of the patient, as far as possible from the anterior superior teeth, to prevent
viewing anything other than the teeth and gingiva of the maxillary arch.
107
This image is critical to evaluate:
• principles of gingival aesthetics:
• gingival contour; and
• gingival zenith (Fig. 18a); and.
• principles dental aesthetics:
• axial inclination (Fig. 18b);
• dental position and arrangement (Fig. 18c); and
• width/length ratio (Fig. 18d).
During the appointment, it is necessary to obtain actual measurements of the face
and teeth with the aid of a mechanical or digital caliper, ie, the interpupillary distance, mou-
th width, width of the smile, width and length of the central incisors and width of the six
anterior teeth. Based on these measurements and the pre-established aesthetic principles
widely discussed in Chapter 2, it is possible to determine the new optimal dimensions,
which allow for making suitable dental sizes for this patient, according to an individual
analysis, and not from common patterns of the population (Fig. 19). Thus, the cosmetic
rehabilitation planning becomes individualized, being based on the particular dimension of
the patient.
A relevant factor in the planning of an aesthetic rehabilitation is to consider the differen-
ce between the evaluation of teeth with their actual anatomical width and their optical width.9
When measured directly within the mouth and when measuring with the use of digital photo-
graphy planning, teeth have different dimensions, especially with respect to the width, since
the frontal view of the patient does not coincide with the dental frontal view. (Fig. 20) This oc-
Figure 18. Gingival contour with small length discrepancy of the canines compared to the centrals. Gingival zenith of canine positioned further down; (a) ideal axial inclination (b) and laterals are within the
horizontal lines drawn between the gingival zeniths of the central incisors and canines (c); width/length ratio (18d).
108
Operative Dentistry – Ideal Dimensions
Central Incisor Lateral Incisor Canines Length x Width - Ratio
63 Lateral Width Canine Width 100% 75% 85%
Width of the Width of the

Central Incisor Central Incisor
0,5 or = CI
C.I. Width C.I. Width
-0,5 to 1,5mm
-25% -15% 7,9
÷ 6,6 ÷ 7,2 6,97
(x0,75) (x0,85) With Diastemata
9,54 8,75 Check with D.I if it is greater the maximum
acceptable refer to Orthodontics
x1,33 x1,25 x1,33 x1,25

Lateral Length Canine Length
12,68 11,92 10,93 11,63
Equal to the Length of Equal to the Length of
the Central Incisor the Central Incisor
Minimum and x y z
maximum acceptable
length of the central incisor x+y+z= 18,6 ÷ 2 = 9,3
-0,5 or equal
-0,5 Measurements For Wax-up
Selected Design of the C.I. -0,5 à 1,5mm -0,5 à 1,0mm
Width Length -1,0 -0,5 11,62 10,1 11,12

11,62
9,3 INCISAL CERVICAL Final Value = 11,12
9,3 6,97 7,9
Final Value = 10,1
Figure 19.
Figure 20.
Figure 19. Schematic instructional drawing of the ideal dimensions (width/length) calculations .
Figure 20. Ideal widths measured in photography in the digital planning. The teeth have different dimensions, since the frontal view of patient does not match the tooth frontal view.
109
Figura 21a.
Viewer
Maximum rotation
of the central
incisors is 25º
Figura 21b.
Optical width
Anatomical width
Figura 22.
Figure 21. Another case as an example, the maximum acceptable rotation of a tooth in an acceptable digital planning is 25º (a) from the optics of the
observer, confirmed by the transferor. When the tooth rotation is greater than 25º, the digital tracing loses its validity, as it starts to suggest an unreal
contour, since the screen is “2D or two-dimensional,” and the smile, “3D or three-dimensional”. Rotation beyond 25 ° is already applied starting from the
lateral incisors, invalidating the tracing in relation to the width of the future designed teeth (b). In this photo one can see, through digital rules calibrated
previously, the width of the lateral incisor is different when we have the digital (observer/computer) and anatomical view of the same element. The
transferor shows the 41º of natural rotation of the upper arch, preventing any assumed digital trace for the definition of the actual width.
Figure 22. Actual anatomic width compared to the optical width.
110
curs as a consequence of inclinations of the teeth, the shape of the dental arch, rotations of
teeth and any possible overlapping of a tooth with another.9 Therefore, when calculating the
optimal tooth size from the interpupillary distance, and considering all the facial aesthetic
references,the values obtained for the width of the teeth can not be applied directly on the
frontal photo of the smile or even with retractor to make it appear wider than ideal, gene-
rating an overlap and consequently a confusing planning effect. From the patient’s frontal
view, the only teeth that appear in an anatomical frontal position are the central incisors;
as we move towards the posteriors, the other teeth will suffer spins on the arch, which
generate a downward effect from their optical width.Therefore, when mounting the digital
simulation of the ideal dimensions of the patient, it is necessary to consider the rotation of
teeth within the arch and the effect of reducing their widths posteriorly. (Fig. 21a-b) For this
reason, digital planning should be used judiciously, and it should be explained to the pa-
tient so as not to generate a misguided virtual presentation of the actual outcome. (Fig. 22)
d) Photo with Shade Guide (Fig. 10m)

For proper shade registration of the patient’s teeth during treatment and especially
for communication with the laboratory, three photos are recommended to be taken with
the use of a shade guide placed next to the teeth: one of the smile, one in occlusion with
a retractor and one with retractor and contrast when taking the photograph. The shade
guide should be placed incisally with relation to the teeth in the same horizontal plane as
the central incisors, or as close to this plane as possible, without tilting, so as to eliminate
any possible variations in the amount of light received, which would cause variations in
shade registration.
e) Occlusal Maxillary (Fig. 10n)

Occlusal photographs are always obtained through image reflection, with the highest
quality mirrors. For this shot what is interesting is to increase the aperture (to decrease the
f-stop values from 14 to 16), since the ability of the flash to illuminate the scene being shot
is smaller, because it is a mirror image. Also, since all of the teeth are on the same plane,
the aperture is more than sufficient for the whole occlusal plane to appear completely.
Keeping the mirror clear with the aid of a mild jet of air with its posterior portion as far as
possible from the molars, the teeth of interest should be included in the frame, with the
entire arch placed in the center of the photograph, and with the patient’s mouth opened
as wide as possible.
The angle of the mirror should be arranged so that the reflected image offer condition
of a shot as perpendicular as possible to the occlusal surfaces of the teeth, enhancing the
preview of size and shape of the embrasures. Partial inclination of the patient, with the head
tilted back, will help when carrying out the maxillary occlusal photo.
In addition to the mirror, lip retractors must also be used, to remove the lips from the
perspective of the anterior teeth, so that about a third of the buccal surface of these teeth
from an occlusal view may be seen. For the picture to have a good depth of field, it is
suggested to focus on the occlusal of the premolars.
111
f) Mandibular Occlusal (Fig. 10o)
Similarly to the maxillary occlusal technique, lip retractors and mirrors are used, in
addition to the identical aperture settings. Most importantly when taking this shot is to
exhibit the labial embrasures of the anterior teeth as if they were being observed from the
incisal edge, making sure that the angulation of the mirror does not reflect a picture with a
greater highlight of the buccal or lingual surfaces, reducing the possibility of observing the
shape and size of the embrasures.
The photographic protocol is not static; It can and should be adapted according to
the needs of the professional and ceramists, with the exclusion or the addition of photos,
always with the objective of optimizing the inter-communication and favor the accuracy
of the results. Most importantly is to standardize the collection and the storage of images
for later comparisons and observations, to facilitate communication with the patient and
the laboratory, and to create a collection of case histories which can be used in classes,
conferences and research.
In short, today’s high-level Dentistry requires obtaining high quality images, which
requires investment and appropriate training. The aesthetic rehabilitation planning is a tool
that serves as yet another way to optimize communication among clinician, the patient and
the laboratory, in order to minimize surprises in the outcome. It should serve as the basis
for a good waxing and carrying out the mock-up. Finally, this will result in tridimensional
visualization of the proposed treatment planning.
Since all these factors have been studied, individualized to the patient and determi-
ned through of the aesthetic rehabilitation planning, the professional will be in the way of a
WAX-UP TOOTH (Fig. 23)
thorough and accurate diagnosis of the case and be able to create a complete and indivi-
dualized treatment planning. After the preliminary treatment planning is built on the photo-
graphic protocol, one can carry out a wax-up on the stone model, so that the information
is evaluated three-dimensionally. It is necessary to identify the objectives to be achieved
and what changes should be made in smile looking to maximize aesthetics and function.8
The tooth wax-up has several functions, including to serve as a test of the planning
for the dentist, for the technician and the patient when being transferred to mouth as a
mock-up or restorative trial. This allows for all of the features to be achieved in the patient’s
mouth to be analyzed previously to perform any intervention. When one aims to promote
any type of tooth position correction when there will be interference of the original volume
of the patient’s teeth, the wax-up may be left with excessive volume and, at the time of
mock-up, cause surprise to the patient,.16 In this case it is necessary the patient to be
informed that excessive volume will be corrected before the final result, preparations or
by means of some kind of minimal adjustment which can be made in the teeth prior to
impression for wax-up, thereby obtaining a more accurate model for the desired final
outcome and a more pleasant mock-up. Another less realistic possibility is the exclusive
presentation of digital planning without producing any preparation prior to the acceptance
patient’s for making the wax-up and completion of the mock-up.
112
The wax-up, still, may be applied in the production of a reference guide for the tooth
preparation which is not to be based on the existing tooth contour, but rather on the ex-
pected final volume, allowing for one to obtain the final porcelain restoration with an uniform
thickness and improved strength of the tooth-restoration set.16
The wax-up may still be used in the production of a silicone guide, which may be
utilized when carrying out the provisional restorations, to facilitate obtaining an aestheti-
cally pleasing result as well as maling it possible for the patient to adapt to the new dental
dimensions and shapes.25
For the accomplishment of the wax-up detailed knowledge of dental anatomy is
required, along with intuition, sensitivity and good perception of the patient’s personality
and his expectations.16 Using the information of the ideal aesthetic principles, dental and
facial measurements, and photos, the aesthetic rehabilitation planning makes it possible
to determine the ideal lengths and widths of the teeth, in addition to the ideal shape. All of
which may be reproduced in the wax-up and distributed in the cervicoincisal and mesio-
distal directions in the rehabilitation outline.
Cases of reconstructions and extensive aesthetic restorations should comply with
all of the previously described steps, in order to achieve the desired result. These cases
are carried out three times, using three different materials, wax, acrylic resin and porcelain,
each of which confirms the steps above, to achieve the best final result. By following them
the final rehabilitation work is transformed into a certainty and places the entire planning
in the hands of the dentist, without surprises, guesswork or assumptions, based on true
measurements and real possibilities.
Figure 23.
Figure 23. Tooth wax-up accomplished with white wax (Inowax®, Formaden, Brazil) from the ideal dimensions established by the facial reference. Notice that the wax-up was carried out over the gingiva
of the stone model of teeth #13, #14, #25, #24 and #25. These teeth, according to Figure 18, exhibited a gingival zenith slightly below the ideal.
113
With the wax-up in hand the mock-up or restoration try-in should be performed,
MOCK-UP
which corresponds to a test of the initial planning, carried out directly in the patient’s
mouth. Before carrying out any preparation within the patient’s mouth, it would be ideal if
the patient could evaluate and approve the mock-up, and know exactly what to expect
from the treatment so that the dentist, may please him. The mock-up should be shown
to the patient, and the professional should help them go over and verify that the aesthetic
rehabilitation planning, the digital planning and wax-up performed are compatible with their
personality, face, smile, masticatory function and subjective expectations,16 as well as
presenting any possible limitations of the results which are dependent upon the patient’s
initial conditions.
This procedure may be performed on study models through the wax-up and subse-
quently transferred to the patient’s mouth using bis-acrylic resin or PMMA resin; or even
as a direct intraoral restorative trial performed with composite resins.6 Mock-up types are
presented below and in Table 2:
• Direct mock-up with composite resin: characterized by the transfer of the aesthetic
rehabilitation planning directly into the patient’s mouth with light-cured composite
resin. Typically carried out with enamel resins due to its excellent polishability and im-
mediate mimetism using ceramics, applied in a single layer over each tooth without
any acid etching, distributing the resin in a cervicoincisal and mesial-distal direction,
and shaping the tooth as established by the planning, always to be based on the
prescribed aesthetic principles. Despite the imperative necessity to manipulate the
composite resin with dexterity and of offering an idealized morphology which inclu-
des application, finishing and polishing, this technique saves time between appoint-
ments.(Fig. 24a-K)
Figure 24. Direct mock-up with composite resin. Insertion of the composite resin (Beautifil® II, Shofu, Japan), shade BW, on the tooth structure, without hybridization using the appropriate spatula (a);
accommodation of composite resins with specific brush (Shofu®, Japan), which defines the tooth morphology (b); use of coarse-grained diamond discs (Sof Lex Pop-On®, 3M ESPE, USA) for correction
of anatomical details (c-e). This step is carried out post-polymerization and evaluation of the patient from the frontal aspect. The most practical way to carry out this evaluation is to have the patient
positioned seated and facing the observer. So the dentist, with a direct frontal view, may analyze and evaluate any possible previously imperceptible details, when the patient was lying; preparation of
surface texture with a ultrafine diamond point (Komet®, Ale) (f); fine polishing with abrasive rubbers for composite resin (Composite Technique Kit®, Shofu®, Japan) (g-h); final gloss established with goat
wheels (i); and final result of direct mock-up (j-l).
114
Figure 24c. Figure 24d. Figure 24e.
Figure 24f. Figure 24g.
Figure 24h. Figure 24i.
115
Figure 25. Indirect mock-up with bis-acrylic resin. Fabrication of a high viscosity silicone guide, preferably laboratorial (Zetalabor®, Zhermack, Italy) (a); high viscosity silicone guide relined with low viscosity
material (Oranwash®, Zhermack, Italy) (b); cross-section of the guide with a #12 scalpel blade about 2 mm above the gingival margin to facilitate the removal of excess bis-acrylic resin (c); dispensation
of bis-acrylic resin into the guide, which is brought to the patient’s mouth (d); removing excesses after 5 minutes with explorer (e); result after immediate removal of the guide (f); after cleaning with gauze
soaked in alcohol (g); and excess removal with #12 scalpel blade (h).
116
• Indirect mock-up with bis-acrylic resin: where the aesthetic rehabilitation planning is transferred to the patient’s mouth
with bis-acrylic resin. Despite its good finishing and polishing characteristics, bis-acrylic resins are monochromatic
and may cause great estrangement to the patient with respect to the immediate result. Therefore, it is recommended
to carry out a wax-up that offers not only the ideal dimensions, but a maximum of morphological and surface texture
features. In this manner, the reflection of light is controlled, so that what will be valued is its highlighted idealized dental
morphology. (Fig. 25a-h)
• Indirect mock-up with acrylic resin: differs from the mock-up with bis-acrylic resin due to the rigidity of the acrylic
resin mock-up, fabricated in the laboratory. Despite its excellent polychromatic property, it is possible to be applied
and exhibit an excellent finishing and polishing, the high cost must be taken into consideration, except for cases of
anticipated periodontal surgery, inwhich this technique is preferable (Chapter 2, page 53, Fig. 26a-d).
Table 2. Characteristics of each of the three types of mock-up explained in chapter.
COMPOSITE RESIN MOCK-UP BIS-ACRYLIC RESIN MOCK-UP ACRYLIC RESIN MOCK-UP

Clinical stage for the Mean clinical time (±1 h) Mean clinical time (±1 h) Short clinical time (±15 min)
execution of the mock-up . . .
Time between impression/ Absent Short . Long
wax-up and execution of . . .
mock-up . .
Laboratorial stage Absent Only wax-up Difficult and elaborate
Costs Low Low High
Demarcation of the initial Regular Good . Excellent
incision line . .
Finishing and polishing Yes Yes . Yes
adjustments . . . .
Handling Operator-dependent Hard Easy
Use during the surgical Regular Good . Excellent
procedure . . .
Polishing and texture Excellent Good Excellent
Before the explanation and all of the characteristics are evaluated, the authors preferably recommend using the bis-
-acrylic resin indirect mock-up for clinical evaluation as well as for presentation of the aesthetic rehabilitation planning. Such
a condition does not rule out the use of another type of mock-up, the indication and performance of which depend upon
the preference and skill of the operator, speed, available working time, evaluation of labor costs etc. That being said, di-
rectly below some steps have been presented towards the establishment of a predictable protocol to carry out an efficient
mock-up, which will lend important and valuable information to the planning of each case.
1. Fabricating the PVS guide

Accomplishment of the mock-up is obtained through the necessary use of a silicone guide as faithful as possible to
the wax-up, transfering to the patient’s mouth the maximum of morphological details and surface texture which has been
preestablished, taking into account the monochromatism of the bis-acrylic resin used for this process, which minimizes the
aesthetics of this assembly. For this, the following techniques have been suggested:
A. Fabrication of a wax-up faithful to the designed aesthetic planning rehabilitation, reproducing morphological details
and surface texture. (Fig. 23)
B. Fabrication of a high-viscosity silicone guide, (preferably a laboratorial silicone, Zetalabor®, Zhermack, Italy), firmly applied
over the waxed model, involving the entire buccal and lingual surfaces, with sufficient thickness to facilitate the correct
positioning in the mouth. It is necessary to involve one to two teeth on both sides, beyond the planned rehabilitation, to
facilitate the stabilization of the guide and avoid displacement which may lead to deformations in the final result of the
mock-up. (Fig. 25a)
117
C. After polymerization, the high-viscosity silicone guide is removed from the model and
relined with a low-viscosity silicone (Oranwash®, Zhermack, Italy), without creating
a relief, which will allow for the best reproduction of the morphological details and
surface texture of the produced wax-up as well as for the installation of a mock-up
with less excess and a more refined anatomy. (Fig. 25b)
2. Trimming the guide with scalpel blade

To facilitate the removal of excess bis-acrylic resin, the guide must be trimmed with
a #12 scalpel blade, approximately 2 mm above the gingival margin, following the contour
of the waxed teeth, so that there is a minimum amount of resin in the region as well as
allowing for it to be easily displaced. It would be ideal if the palate was also cut in order to
allow for the outflow of excess resin from the region as well as to avoid any overcontours
of the mock-up.16 (Fig. 25c)
3. Dispense the bis-acrylic resin in the guide and lead to the patient’s mouth
After discarding the small initial portion, which normally does not polymerize, into the
self-mixing dispenser, it should be applied to the guide so that the first portions are placed
with the mixing tip touching its bottom. This maneuver minimizes the formation of bubbles
within the mock-up and helps promote uniform distribution of the resin into the guide. The
loading of the guide is performed in an agile manner, due to the rapid polymerization reac-
tion of this material, which then must be placed into the patient’s mouth and pressed and
held firmly into position. For this, occlusal pressure should be exerted on the guide over
the teeth which are not involved in the rehabilitation, in order to allow for the complete and
correct seating of the assembly and the proper overflow of any excess material that should
be immediately light cured, facilitating its removal before the 5 minutes of the final chemical
polymerization of the assembly into the guide.16 The correct positioning of the guide also
directly influences the thickness of the mock-up, possibly leading to an incorrect patient
evaluation.16 (Fig. 25d)
4. Remove excess
After 5 minutes, before the removal of the guide, the overflow excesses of the bis-
-acrylic resin, both on the buccal surface as well as on the palate, may be removed with
a dental explorer so as to minimize any future adjustments to be carried out later with a
scalpel blade. (Fig. 25e)
5. Remove the guide and cleanse the mock-up

Five minutes after the polymerization of the bis-acrylic resin and removal of the over-
flowed excesses, the guide may be carefully removed from the patient’s mouth. With an
alcohol-soaked gauze, to remove the unpolymerized superficial layer of the bis-acrylic
resin which was inhibited by oxygen. (Fig. 25f-g)
6. Relining and removing cervical excesses

Small repairs may be carried out if there exist any bubble formation or excess loose
118
resin portions. The literature reports the difficulty of performing bis-acrylic resin repairs,1,2
but since the mock-up should only be used for a short time, this may be accomplished
without any surface preparation, by the addition of composite resin of the the same shade
as that of the bis-acrylic resin used. Excesses which still may exist on the cervical can be
removed with a #12 scalpel blade. (Fig. 25h)
7. Analyze, adjust and photograph the mock-up

With the mock-up in position, the initial evaluation is performed by the dentist. Some
aspects should be evaluated, such as the tooth length, width and its relationship to the lips,
face and other elements. At that point, phonetic tests should also be performed and occlusal
as well as aesthetic adjustments as needed.16 (Fig. 26 e 27)
The second analysis must be carried out by the patient. Prior to that, the patient must
be informed that bis-acrylic resin is monochromatic and that while the teeth are joined
together, this will not be the case in the final rehabilitation. The mock-up serves to present
the possible aesthetic and functional results, as well as the morphological features which
may be obtained with the rehabilitation so as to add something tangible to the aesthetic
rehabilitation planning, that the patient can see and experience before any procedure is
performed within the patient’s mouth.16 In front of a mirror, the patient has the opportunity
of evaluating the preliminary result and propose minor changes to the mock-up, that may
even be performed immediately provided that it is clinically possible and that it does not
compromise the aesthetic rehabilitation planning. If there are changes, it is recommended
to carry out the impression with (high- and low-viscosity) addition silicone of the modified
mock-up, which should then be stored and the information transfered to the lab techni-
cian. It is also necessary to take photos of the patient with the mock-up, repeating the
photographic protocol explained earlier on in the chapter, in order to acquire as much
comparative information of this trial as possible.
Figure 26. Evaluation at rest after installation of the indirect mock-up with bis-acrylic resin.
Figure 27. Smile analysis after completion of the indirect mock-up with bis-acrylic resin.
119
It is not recommended that the patient leaves the office with the mock-up installed for several reasons, including the
difficulty of hygiene, since the teeth are joined, which may lead to the formation of gingival inflammation if it remains in the
mouth over a long period. In addition, there is a risk of interference from the opinions of others, during the process, by
people who do not understand the clinical stages and its nuances, ending up issuing negative and impertinent opinions,
which may lead the patient dropping out of the treatment.
The mock-up is now mandatory in the execution of ceramic veneers, since it is an excellent tool for optimizing perio-
dontal surgery (Fig. 28) and hence for further rehabilitation (Fig. 29a-h).
The mock-up holds a key role in the difficult task of defining the necessity or not of for tooth preparation in the making
of ceramic veneers. It serves to reveal the exact location where it is required to perform a small or a large reduction of the
tooth structure. In Figure 30 it is possible to observe the presence of a slightly buccal left lateral incisor and an extremely
fine direct mock-up, with a small chipping on the mesial edge. This situation ultimately confirms the precise location of any
future reduction. Therefore we may conclude that the mock-up also occupies a role as a reduction guide, especially for
prepless ceramic veneers or those with minimal reduction.
Figure 28. Figure 29a. Figure 29b.
Figure 29e. Figure 29f. Figure 29g.
Figure 28. Appearance after healing of the gingivoplasty for correction of gingival contour.
Figure 29a-h. Final result after installation full ceramic veneers without preparation.
120
Figure 29h.
Photography performed by Dudu Medeiros.
121
Figure 30i. Figure 30j.
Figure 30. Initial appearance, which reveals the presence of discolored teeth, incisal edge of tooth 22 worn and 21 slightly proclined (a-b); incisal view confirming slight proclination of the tooth 22 (c);
appearance after preparation of the direct mock-up with composite resin in the teeth 21 and 22 (d); detail which reveals the presence of an area with enhanced brightness on the mesial vertical edge
demonstrates the presence of tooth structure at this location (e); aspect of the composite resin mock-up after removal of the tooth 22. Note that there was perforation of the mock-up for the absence of
composite resin (f); after reduction in mouth of this vertical edge, impression taking and preparation of the working model were performed which will later be used for making the ceramic veneer of tooth
#22 (g); aspect after cementation fragment of tooth #21 and veneer of tooth #22 (h); and final smile (i). Ceramist responsible: Leonardo Bocabella.
122
Guided by aesthetic principles and combined with a group of essential tools such as
CONCLUSION
the photographic protocol, precise wax-up and mock-up, the aesthetic rehabilitation plan-
ning is carried out in a predictable and individualized manner, along with the establishment
of an ideally universal aesthetic planning, relieving thereafter the unsuitable intuitive ability
of the professional in this process. It is evident that the time spent on these steps genera-
tes time saving in the try-in phase of the veneers and minimal stress on the doctor-patient
relationship, achieving ones expectations without major difficulties.
1. Bohnenkamp DM, Garcia LT. Repair of bis-acryl provisional restorations using flowable composite resin. J Prosthet Dent.
REFERENCES
2004;92(5):500-2.
2. Burns DR, Beck DA, Nelson SK; Committee on Research in Fixed Prosthodontics of the Academy of Fixed Prosthodontics.
A review of selected dental literature on contemporary provisional fixed prosthodontic treatment: report of the Committee on
Research in Fixed Prosthodontics of the Academy of Fixed Prosthodontics. J Prosthet Dent. 2003;90(5):474-97.
3. Calamia JR, Levine JB, Lipp M, Cisneros G, Wolff MS. Smile design and treatment planning with the help of a comprehensive
aesthetic evaluation form. Dent Clin North Am. 2011;55(2):187-209.
4. Christensen GJ. Important clinical uses for digital photography. J Am Dent Assoc. 2005;136(1):77-9.
5. Davis NC. Smile design. Dent Clin North Am. 2007;51(2):299-318, vii.
6. Decurcio RA, Cardoso PC, Rodrigues DC, Corrêa EJB, Borges GJ, Sulaimen AMM. O uso do mock-up na otimização e
precisão do resultado da cirurgia plástica periodontal. Clín – Int J Braz Dent. 2012;8(1):74-85.
7. Essen SD. Digital imaging in dentistry. Todays FDA. 2011;23(6):62-8.
8. Goodlin R. Photographic-assisted diagnosis and treatment planning. Dent Clin North Am. 2011;55(2):211-27, vii.
9. Hatjó J. Anteriores: a beleza natural dos dentes anteriores. São Paulo: Santos; 2008.
10. Hutchinson I, Williams P. Digital cameras. Br J Orthod. 1999;26(4):326-31.
11. Llop DR. Technical analysis of clinical digital photographs. J Calif Dent Assoc. 2009;37(3):199-206.
12. Lutke G. Beyond the basics in digital photography. Todays FDA. 2012;24(3):55-7, 59.
13. Machado AW, Leite EB, Souki BQ. Fotografia digital em ortodontia. Parte IV: Sugestão de equipamento. J Bras Ortodon
Ortop Facial. 2004;9(52):323-7.
14. Machado AW, Oliveira DD, Leite EB, Lana AMQ. Fotografia digital x analógica: a diferença na qualidade é perceptível? R
Dental Press Ortodon Ortop Facial. 2005;10(4):115-23.
15. Machado AW. O que há de novo em fotografia digital? R Dental Press J. Orthod. 2010;15(2):20-3.
16. Magne P, Belser UC. Novel porcelain laminate preparation approach driven by a diagnostic mock-up. J Esthet Restor Dent.
2004;16(1):7-16; discussion 17-8.
17. Masioli MA, Masioli DLC, Damazio WQ. Fotografia digital na clínica diária. eBook XXV CISOP. São Paulo; 2007.
18. Masioli MA. Fotografia odontológica. Vitória; 2005.
19. McLaren EA, Garber DA, Figueira J. The Photoshop Smile Design technique. Part 1: Digital dental photography. Compend
Contin Educ Dent. 2013;34(10):772-6.
20. McLaren EA, Schoenbaum T. Digital photography enhances diagnostics, communication, and documentation. Compend
Contin Educ Dent. 2011;32(4):36-8.
21. Medeiros D. Click Dudu Fotografia Odontológica & Marketing. São José; 2013.
22. Morris M. Digital photography: your modern communication and marketing tool. Dental Economics. 2009;99(3).
23. Oliveira JP, Martins MF. Fotografia intraoral. São Paulo: Santos; 2004.
24. Paredes V, Gandia JL, Cibrian R. Digital diagnosis records in orthodontics: an overview. Med Oral Patol Oral Cir Bucal.
2006;11(1):E88-93
25. Robinson FGL, Chamberlain JA. Masking technique of cast for diagnostic waxing of labial veneers. J Prosthet Dent.
2007;97(1):56-7.
26. Sandler J, Murray A. Manipulation of digital photographs. J Orthod. 2002;29(3):189-94.
27. Shagam J, Kleiman A. Technological updates in dental photography. Dent Clin North Am. 2011;55(3):627-33, x-xi.
28. Shorey R, Moore K. Clinical digital photography: implementation of clinical photography for everyday practice. J Calif Dent
Assoc. 2009;37(3):179-83.
29. Snow SR. Assessing and achieving accuracy in digital dental photography. J Calif Dent Assoc. 2009;37(3):185-91.
30. Trevisan F, Scanavini MA, Maltagliati LA, Gonçalves RR. Adaptações em câmera digital compacta para obtenção de fotogra-
fias intrabucais. R Clin Ortodon Dental Press. 2003;1(6):81-6.
123
SECTION II. BEFORE
OPTIMIZATION OF THE Aesthetic AND FUNCTIONAL RESULTS
chapter 5.1
Orthodontics as a differential for pretreatment
ceramic veneers
Juliana Romanelli
Orthodontic treatments have become increasingly indispensable in the context of
INTRODUCTION
multidisciplinary dentistry which interacts with virtually all specialties, whether directly or
indirectly. Oral rehabilitations can be extremely conservative when orthodontics is incorpo-
rated into the planning, from extensive treatments to the preparation of a single ceramic
veneer.
The evolution of cosmetic dentistry has been based on, among other things, the se-
arch for naturalness in the work to be performed and the maximum preservation of dental
structures. The proposal of minimally invasive treatments, and even without tooth prepara-
tions, has been well addressed and discussed in the literature.9,19,20
Many are the approaches from orthodontics for optimizing the results of the resto-
rations in aesthetic areas,21 which include the betterment of the surrounding soft tissues,
approaches of which clinicians and rehabilitating specialists often are unaware, which
reduces the possibility of more comprehensive planning.
The predictability, beauty and longevity of ceramic works is strongly related to their
correct planning. Ceramic veneers, especially for their delicate thickness, deserve due
attention as to the positioning of the teeth from various angles, especially when consi-
dering the need for subtle reductions, inherent to this technique. Poorly positioned teeth
may condemn the indication of veneers, changing the treatment option to full crowns and
involve the possibility of endodontic treatments.
Prior repositioning of the teeth can prevent these unwanted procedures and provide
the desired conservative or even the elimination of preparations in most rehabilitation cases,
positively changing the prognosis of involved teeth.15
The transition zone,8 composed of the cervical region of the prosthetic restoration
and adjacent soft tissues, also had its importance uplifted with the advent of the supra-
gingival preparation as well as at the level of the gingiva.9 The frequency of retreatments
in dental practices accompanied by complaints of inflamed gingival margins of prostheti-
cally-restored teeth lead the rehabilitation specialist to seek in orthodontics, through rapid
orthodontic extrusion (ROE), a way in which expose the subgingival preparation, so that
the teeth may then be retreated in the proper manner.13,16
With respect to the entire work, the gingival architecture which directly composes
the patient’s smile has been studied for a long time. Accordingly, the gingival architecture
should obey the leveling harmony, seeking to mimic the design sketched out by the cer-
vical and incisal levels of the anterior teeth in relation to the curvatures of the upper and
lower lips.2,4,9 This contour can, if non-existent, be constructed by way of simple orthodon-
tic leveling, prior to the rehabilitation. In cases where there are injuries with bone loss and,
consequently gingival within this aesthetic region, slow orthodontic extrusion (SOE) can
rebuild this architecture even the red aesthetics, principally with regard to the limitations or
asymmetries in the heights of the interdental papillae.5,14,18
The long treatment time, characteristic of orthodontics, and usually the patient’s
main complaint, may be abbreviated when it is solely performed within the region to be
rehabilitated. This may be considered minimalistic orthodontics,14 ranging from 6 to 12
months with results only to the composition of the rehabilitation treatment, and not ma-
locclusion, when present. This concept should be extremely well clarified to the patient,
128
because the election of the partial treatment should be a shared responsibility with the
patient who will have the appliance installed and still have the possibility to opt for a total
correction. In some situations, the malocclusion, is the very cause of the trauma that
leads to the loss of tooth structure (gingival recession, abfraction, enamel crazing and/or
the incisal edge, etc.), thus the proposal for minimalistic orthodontic treatment should be
discarded from the very beginning.
The most requested forms of orthodontic preparation for aesthetic rehabilitation, for
presenting the most significant benefits will be addressed in this chapter and may be
viewed in the illustrations and/or within each clinical case.
In order to present results with excellent aesthetic finishing, there are some strategic
ORTHODONTICS APPLIED
TO AESTHETICS
orthodontic movements to be performed prior to the restorations. These maneuvers are

quite predictable and in most cases very simple. Such procedures may improve, encou-
rage or even make possible the preparation of ceramic veneers.
For orthodontics to be recognized beyond the standard occlusal correction, it objecti-
vely follows the most significant movements or orthodontic techniques, be those of a short
duration, targeted towards a prosthetic approach, beyond their orthodontic indications and
benefits.
It is worth noting that these approaches demonstrate the opportunities provided
by orthodontics, even when it does not coincide with the best aesthetic solution, some
situations do involve limitations inherent to cases in which ones optimal movements are
restricted, as in the case of vertical incisal leveling.
LEVELINGS
Vertical gingival leveling
This being the most suitable form of vertical leveling in the pursuit for the harmony of
a smile, principally when it involves aesthetic restorations of the gingival smile.
The concept of gingival architecture is comprehensively addressed in Section II, of
Chapter 5.2. In summary, it should be based on the cervical contours of the maxillary ca-
nines and central incisors, where their zeniths should be symmetrical and positioned 0.5
mm to 1.5 mm more apically in relation to the respective lateral incisors.10 This is where
minor variations of the canine, slightly above the height of the central incisor are conside-
red harmonic.
The construction of this architecture through orthodontics in patients without any
osseous or gingival defects becomes an extremely simple procedure, performed only with
the correct positioning of brackets (utilizing braces). This positioning should preferably be
designed prior to bonding, whre the heights are predetermined from the gingival to the
incisal. In most current techniques, the starting point should be the canine, whose height
of bonding should initially be determined. Then the following heights of the remaining teeth
129
will be calculated towards the central incisor, respecting the triangular shape with an inver-
ted base between the heights of the cervical of the canines, lateral and central incisors4
(Fig. 1a). The accuracy of the heights varies according to the orthodontic technique and
should respect the height/diameter of the crown.3 If orthodontics opts to use a technique
of sequential acetate aligners (eg, Invisalign®, USA), its planning should involve that archi-
tectural condition during the gingival leveling.
Case 1 involved a patient seeking rehabilitation with veneers, but presented gingival
recession throughout the anterior region (Fig. 1b). She was previously submitted to root
coverage surgery throughout the anterior-superior region, although the right side did not
obtain the same degree of success as the left side (Fig. 1c).
The passive auto-ligating device (Damon Clear,® Ormco, USA) elected was initially
installed in a passive manner, for occlusal reorganization (Fig. 1d). After the occlusal leve-
ling, still at an early stage, the brackets of teeth #13, #12 and #11 were purposely reposi-
tioned more gingivally (during different appointments, not in the same activation, being that
they are sequential), which promoted the extrusion of the anterior right segment, obtaining
the leveling of the cervical and papilla, not fully achieved through the coverage surgery. In
addition to the vertical movement in the incisal direction, tooth #11 also had its long axis
corrected because it presented mesial tilting of the crown and distal tilting of the root. The
existing height difference between the maxillary centrals could then be verified, dissimula-
Figure 1a. Gingival vertical leveling.

Figure 1b. Initial image with gingival recession.
Figure 1c. Results of the gingival surgery with significant improvement on the left side.
Figure 1d. Orthodontic appliance installed.
130
ted by the inclination of tooth #11 (Fig. 1e). The appliance was removed, the preparations for ceramic veneers were carried
out (Fig.1f), and the porcelain restorations were installed (Fig. 1g). The case was followed up for 12 months (Fig. 1h).
The premise for orthodontic leveling of this case was gingival vertical, to increase the harmony of the patient’s smile
composition for the preparation of veneers. This change may be observed when comparing the initial and the 12-month
contention phase (Fig. 1i-j). Nevertheless, blended to the proposal of this case, a minor slow orthodontic extrusion was
carried out with the intention of also leveling the heights of the interdental papillae obtained by the symmetry of the alveolar
bone crests brought about by the extrusion.
Regarding the type of orthodontic appliance chosen for the gingival leveling, both fixed appliances as well as aligners
may be used with a high degree of success without any restrictions.
Figure 1e. Result of the gingival leveling, and axial improvement in the central incisors.
Figure 1f. After orthodontics, the preparations for ceramic veneers.
Figure 1g.Veneers installed after the established leveling.
Figure 1h. Case follow-up at 12 months.
Figure 1i. Initial smile, after gingival surgery.
Figure 1j. Final Smile with 12 month follow-up.
131
Vertical incisal leveling
This is not to be the ideal orthodontic planning for rehabilitation, beyond the fact
that its indications are even being restricted. For this leveling, the incisal harmony is what
guides its accomplishment. In that, the line that touches the edges of the canines and in-
cisors should be parallel to the curvature of the lower lip.4,9 Based on this design (Fig. 2a),
the incisal vertical leveling is then formatted by the orthodontic treatment, when indicated.
There is no report on this leveling as of a protocol for the aesthetic phase of rehabilita-
tion. In this case, the result will not always present harmony within the cervical region and in
the smile composition, since it depends upon the proportionality of the heights of the crowns
for the same to occur within the gingival region. However, this is an alternative in cases where
there may be inherent patient limitations. These various limitations can be physical or perso-
nal, such as the inability to undergo gingival plastic surgery (recontourings) and the inability of
to accep tooth preparations beyond those compromised, often indispensable to achieve an
excellent result. If the smile height is favorable to the case, and does not expose the gingival
region, this becomes a fairly acceptable option to be considered.
In case 2, the patient only presented the tooth #21 to be rehabilitated although a slo-
pe existed which was inasmuch gingival as it was occlusal (anteroposterior and vertical) in
the anterior region. The patient’s complaint was both anterior crowding and the darkening
of the restoration of the tooth #21 (Fig. 2b).
If the treatment was accomplished directly by aesthetic rehabilitation, there would
be a need for extremely invasive preparations in most of teeth, and the risk of endodontic
treatment for tooth #22.
Due to the objection of most adult patients with respect to the use of fixed orthodontic
appliances, the selected appliances (and properly indicated) for this treatment were the
sequential acetate aligners (Invisalign®, USA), completely aesthetic, removable and comfor-
table.
The posterior occlusion did not display relevant issues; the anterior region merely
presented crowding, as much in the lower as the superior arch, and a moderate deep
bite (Fig. 2c), with the central incisors verticalized in relation to the lateral incisors and the
canines extremely palatinized (Fig. 2d-e).
Two distinct approaches were proposed for the patient, with planning that featured
virtual set-ups, through the use of a software (ClinCheck®, Invisalign®, USA). In the first,
and more commonly indicated, leveling takes place from the gingival margins. However,
after the orthodontic stage, part of the restorative treatment would involve tooth #21, por-
celain fragments on the canines and reduction of the mesial of tooth #11, as well as its
preparation and restoration using a ceramic veneer.
In the second planning, orthodontic leveling was accomplished only by the incisal ed-
ges, and in the most conservative manner. The only tooth to be involved in the restorative tre-
atment would be #21, as was the intent of the patient from the beginning. The patient opted
for the latter planning, acknowledging that it would be less harmonious, but more conservati-
ve. The result presented an orthodontic treatment which exactly achieved the expectation of
the patient and permitted the restoration of tooth #21 with a ceramic veneer and an adequate
design established by the incisal edges of the anterior teeth (Fig. 2f).
132
The bite was finished with an adequate ammount of overlap (Fig. 2g), and the inclinations of the incisors and canines
along the arch became harmonic (Fig. 2h-i).
The initial smile exhibiting half-open mouth showed discrepancies along the long axis and inclinations of both the
maxillary as well as the mandibular teeth (Fig. 2j), an improvement seen in the final photo (Fig. 2k). The reasonably low
position of the upper lip while smiling, observed in this last photo, favored the fact of not having gingival harmony in the
composition of the final aesthetics.
As in the previous case, this treatment could also be performed with fixed appliances of a variety of techniques, and
the success rate would have been the same.
Figure 2a. Vertical incisal leveling.

Figure 2b. Initial image, in which the vertical gap may be verified, in addition to tooth #21 to be rehabilitated.
Figure 2c. Initial frontal intraoral view in occlusion with anterior crowding highlighted.
Figures 2d-e Mid right and left profile views showing lingualized canines, and central incisors upright in relation to the lateral incisors.
Figure 2f. Final result with ceramic veneer solely of the tooth #21.
Figure 2g. Anterior final in occlusion demonstrating a suittable amount of overlap and the improvement of discrepancies in the positions of the teeth.
Figures 2h-i Finalization in the middle left and right profile, which shows the harmony of the inclinations of the teeth after orthodontics.
Figures 2j-k. Initial and final smile with mouth half open, showing the improvement obtained with orthodontic treatment followed by rehabilitation of the tooth #21.
133
Occlusal leveling by buccal
This is a fundamental approach which respects the minimally invasive wear assump-
tion for the preparation of teeth, suitable for ceramic veneers.
Occlusal leveling eliminates discrepancies in the anteroposterior direction of tooth
positioning, in addition to the rotations on the axis of each tooth. The purpose of this
maneuver is to align the centers of the crowns of the teeth in an occlusal view, inside the
perimeter of the arch (Fig. 3a). In the vast majority of the cases, the leveling is achieved
from the perspective of the buccal surfaces, respecting the difference in volume inherent
in each type of tooth.
Dental crowding is characteristic of the occlusal slope and realignment allows for
this treatment to be as conservative as possible, within a rehabilitative proposal. When the
teeth present this change (Fig. 3b), the reduction is more invasive in order to compensate
for the excesses and promote leveling. Therefore, the use of orthodontics prior to the
rehabilitation treatment becomes extremely important, to avoid this reductions.
What follows are two clinical cases (cases 3 and 4) inwhich orthodontics was inclu-
ded in the treatment planning. Both cases which showed a significant occlusal uneveness
were treated with sequential acetate aligners (Invisalign®, USA). The benefit achieved with
orthodontics was decisive for the indication of ceramic veneers in the restorative treatment.
Case 3 shows an absence of occlusal leveling with a deep bite, where the maxillary
central incisors were found lingually and the maxillary lateral incisors, proclined. (Fig. 3c-e).
The planning of the maxillary arch targeted realigning this imbalance, which in turn reflected
in the improvement of the deep bite. Along the lower arch, the canines were significantly
mesially inclined while crowding between the incisors showed to be moderate (Fig. 3f).
This situation promoted interferences both in the movements of protrusion as well as la-
teralization, eliminating the protective guides. In this case, the planning of the lower arch
involved mild intrusion of the incisors, concomitantly with leveling, to aid in the elimination
of the deep bite.
The treatment was performed in nearly a year, using 20 aligners, and the final result
achieved all the desired goals as well as producing a sound equilibrium of the buccal
surfaces of the teeth (Fig. 3g-j) and elimination of the deep bite; the last of which being
very important for the longevity of rehabilitations with veneers which may be seen when
comparing the before and after treatment results (Fig. 3k-l).
This case, even though unfinished, fullfiled its planning through the use of ceramic
veneers and fragments. The stone model demonstrates the design of the gingival re-
contouring and the veneers to be fabricated (Fig. 3m-n). Nearly the whole rehabilitation
with veneers would be carried out without tooth reduction, through addition. Preparations
would only be necessary in this case in the maxillary central incisors within the areas of
retention, to better accommodate the veneers.
134
Figure 3f. Figure 3g. Figure 3h.
Figure 3i. Figure 3j. Figure 3k.
Figure 3l. Figure 3m. Figure 3n.
Figure 3a. Occlusal alignment based on the center axis of the teeth.
Figure 3b. Occlusal unevenness.
Figures 3c-e. Smile from the front, half right and half left profiles, highlighting the deep bite and divergent inclinations between lateral and central incisors.
Figure 3f. Lower crowding with canines mesially inclined.
Figures 3g-j. The case completed with the same views from the beginning, for further verification of the result.
Figures 3k-l. Initial and final intraoral frontal view showing the elimination of the deep bite and completely leveled teeth.
Figures 3m-n. Stone models demonstrating the planning of the case, and the small addition of porcelain, for carrying out a successful treatment.
135
Case 4 also shows an upper and lower crowding situation with similar characteris-
tics to that of the previous case, alhtough the bite is now crossed in the middle region,
and there exists a top relation in the anterior region (Fig. 4a-c). The patient’s complaint, in
addition to the positioning of teeth, involved the shape of the teeth, rounded and relatively
short, promoting a rather infantile look (Fig. 4d).
The top bite, despite having the inverse characteristics of a deep bite presents con-
tact interferences and laterality in the anterior teeth. As in the previous case, the protection
guides were impaired, and the rehabilitation without the optimal repositioning of the teeth
left the prognosis of treatment uncertain.
The planning with Clincheck® (Invisalign®, USA), with which the end of the treatment
may be previewed before the fabrication of the aligners, gives the orthodontist various
alternatives to be more conservative, ie less invasive or brief, until a choice is made to
have the aligners manufactured accordingly. In this case, planning only looks towards the
aligning and leveling of the teeth for the preparation of the veneers, without the concern
for a full correction of the midline deviation or of the canine guide. Details of which would
already be corrected by the aesthetic rehabilitation, greatly minimizing the orthodontic tre-
Figure 4a-c. Initial intraoral images with upper and lower crowding, along with a top bite.
Figure 4d. Original rounded shape of the teeth.
Figures 4e-g. End of orthodontic phase.
136
atment time and allowing for the choice for a more abbreviated planning than would have
been necessary.
The treatment took up 13 months, and the result can be seen in Figures 4e-g. The
format of the arches had also been improved, which benefits the stability of the new oc-
clusion (Fig. 4h-k).
The wax-up demonstrated no need for reductions for the prosthetic preparation (Fig.
4l), since the shape and position of the teeth would allow for the preparation of the veneers
solely through an increase in their volume. The fragility of the veneers may be checked
in Figures 4m-n, with the completion of the prosthesis at the level of the gingiva, with an
enamel finish.
The final outcome was successful in all of its proposals. The increased tooth length
enabled the desired overlap in addition to the new, more rectangular tooth shape, solving
the initial complaint of the patient (Fig. 4o-q).
The choice of treatment with aligners in these cases were made strictly by the pa-
tients, although the fixed appliance is widely used for this type of leveling.
Figure 4h. Figure 4i. Figure 4j. Figure 4k.
Figure 4l. Figure 4m. Figure 4n.
Figure 4o. Figure 4p. Figure 4q.
Figures 4h-k. Upper and lower occlusal photographs, initial and late orthodontic phase.
Figure 4l. Diagnostic wax-up.
Figures 4m-n Ceramic veneers loose and positioned in the stone model showing the preparations at the gingival level.
Figures 4o-p. Intraoral images of installed porcelain restorations.
Figure 4q. Smile showing the modification of tooth shape.
137
Lingual occlusal leveling
This is a proposal rarely requested, although it is definitely an option in cases with
anatomical irregularities on the buccal surfaces of the crowns. It is very common to carry
out this leveling in aesthetic retreatment when the proposal is to replace old composite
restorations in crowded teeth with porcelain, whether it be veneers or contact lenses.
The uneveness is also occlusal like the previous, whereas the lingual or palatal surfa-
ces are better preserved which prove to be superior guides for successful leveling. Simi-
larly, the restoration will be carried out only on the buccal aspect, although the orthodontic
treatment will be guided by the lingual surface.
Case 5, utilized as an example, has come for retreatment, both orthodontic and
aesthetic.
This patient reported the following history of treatments before attending the clinic:
showed severe maxillary crowding, and for correction had been subjected to rapid or-
thodontic treatment, whereby the patient’s anterior superior teeth were reduced on the
proximal surfaces as well as the adjacent teeth. Still, there was recurrence in the crowding
after some time, but the proposal given to the patient at that time involved using composite
resin veneers for compensation of the crowding. The result merely camouflaged the real
situation of poorly positioned teeth, although leveling was promoted through the use of
the direct veneers.
When the patient arrived at the dental practice, she was looking for a solution to the
consistent irritation and spontaneous bleeding in the papillae region. The existing situation
presented strong contact points and long and narrower teeth (Fig. 5a-c), produced by the
Figure 5a-c. Initial intraoral images.

Figure 5d. Upper occlusal initial image, in which can be seen vestibular leveling obtained with additions of resin.
Figures 5e-f. Virtual planning through the ClinCheck® (Invisalign®, USA), initial and final views.
138
narrowing of the space between the teeth and roots, which resorption the alveolar crest.
This resorption resulted in the maintenance of shorter papillae, with an average of 5 mm
from the ridge height to the contact point.22
From the upper occlusal view (Fig. 5d) the actual positioning of the teeth and the
amount of resin used to offset this slope could be seen.
The treatment chosen for this case was the use of sequential acetate aligners (Invi-
salign®, USA), and the planning through the alignment of the palatal surfaces was ordered,
beyond the gap between the teeth, to achieve a superior accommodation of the papillae.
The beginning and the end of the virtual planning may be observed in Figures 5e-f.
Throughout the orthodontic treatment, the teeth were slightly separated, and the
resins became more evident on the buccal surfaces (Fig. 5g), which were to be ground at
the end of this phase, respecting the original axes of the teeth (Fig. 5h), and replaced with
ceramic veneers, without the need for compensations (Fig. 5i-j). With the diameters of the
teeth reestablished, and the contact points well determined, the papillae may, thereafter,
be accommodated at a more incisal height, favorable for the prevention of hyperplasia
and bleeding.
In this particular case, the use of Clincheck® (Invisalign®, USA) for the planning greatly
assists in the leveling of the lingual surfaces. A fixed apparatus could have accomplish
the treatment, but not as quickly or as easily, requiring excessive resin removal at the very
beginning could possibly promote an initially unfavorable aesthetic condition. Another al-
ternative would be through the use of steel wire bends on the fixed appliance, which would
not result in such precise leveling.
Figure 5g. During orthodontics, teeth apart so that the original mesiodistal diameter could be recovered.
Figure 5h. Upon accomplishing the orthodontic phase, the resin reduction and veneer preparations, with leveling performed by the palatine surfaces.
Figures 5i-j. Ceramic veneers installed with space for accommodation of the papillae and occlusal leveling.
139
ORTHODONTIC EXTRUSION
Orthodontic extrusion may be defined as the movement of a tooth towards eruption,
from a tensioning with virtually no resistance, as would occur in its very own eruption. This
is a maneuver actually grounded in this movement, such that it was initially called a forced
eruption.6
Considered a non-invasive, predictable and biological procedure,12 this technique
presents extremely satisfactory results in the maintenance or improvement of the “transi-
tion zone”,8 in pursuit of naturalness in the completion of the clinical case, turning out to
be the differential factor in the treatment. According to Garber,5 the natural aspect occurs
when the soft tissue profile presents the same three-dimensional shape as the contralate-
ral tooth. This rearrangement of the gingival architecture, with the proposed mirroring at the
healthy side, may be obtained with two different orthodontic extrusion proposals.
Rapid orthodontic extrusion (ROE) and slow orthodontic extrusion (SOE) as their
actual names suggest, differ by speed, beyond the amount of force with which the move-
ment is performed. Jointly, these variants will determine the amount of periodontium which
will accompany the tooth.7 These two variations of movement are described below with
their respective indications.
Rapid Orthodontic Extrusion

Some cases come up against unfavorable conditions for implementing the prepara-
tion, such as retreatment in subgingival preparations, presence of carious lesions exten-
ded to the root or even horizontal root cracks very close to the cervical height. All of which
are conditions that may compromise the tooth, the prosthesis to be installed or the future
gingival contour.
A very affordable solution to correct this problem is by modifying the height of the
preparation exposing the defect, carried out through ROE, which draws the tooth in the
occlusal direction, with a heavy force at short intervals, causing the periodontal fibers to
break away. The tooth is extruded until the unfavorable condition is exposed, and then the
fibers are naturally reinserted at a new height. The red aesthetics is unchanged, for there
is no tissue, or bone, or gingival augmentation in this case.7,13,14
This maneuver avoids the subgingival preparation in order to reach the defect. The-
refore, in cases with less favorable defects, there will not be any invasion of the biological
width in the preparation step, which would lead to gingival recession.
Even when there is risk of invasion of the biological space, where the margin of the
prosthesis ends in free gingiva, the tooth may be minimally extruded, and the prepara-
tion will be completely exposed, greatly reducing the chance of contamination within the
prosthesis-tooth interface, common to subgingival preparations. In these cases, traction
is often capable of leading to the ceramic margins remaining in enamel, maintaining the
superior quality of its adhesion.
Slow Orthodontic Extrusion

When there is deficiency in the gingival architecture, especially when comparing an
element to its contralateral, SOE can return the lost structure and favor the gingival aesthetics
140
of the restoration, allowing for a more natural appearance. For this version of the technique,
there is both osseous as well as gingival tissue gain.
The underlying bone architecture has been considered fundamental to the predictability
and guiding of the interproximal soft tissue contour.18 Among the many benefits encountered
through the use of this technique, two should be highlighted. The first of which is the forma-
tion or reestablishment of the interdental papillae, through the possibility of reconstruction of
the alveolar bone crest, in a predictable manner,17,18 promoting support for the nutrition and
maintenance of this gingival triangle. The other is the optimal quality of the bone formed by the
slow extrusion, ie, a highly differentiated bone.16 For the latter to occur, the premises of light
forces, long intervals between appointments and correct timing for post-extrusion contention
must be respected.
A movement carried out slowly and with light forces promotes tensioning of the perio-
dontal ligament, which elongates the fiber bundle and induces osteoblasts to deposit new
bone in areas of the alveolar socket where periodontal retention exists.11 For the formation
of bone to be able to accompany the movement rate, slow extrusion should occur with an
average of 1.0 mm per month.
Slow extrusion has another indication besides improvement of the gingival architecture
of the tooth to be restored. Since the early 90s, it has been found that even when the tooth
was condemned, manipulation of this element could substantially improve the environment
where the implant would be installed, provided that it presents a certain amount of periodon-
tium adhered to the root in the region of the loss.17
The post-extrusion stabilization comes as the third important point to ensure the suc-
cess of the extrusive treatment. After the movement is completed, the tooth should be im-
mobilized, still accompanied by the orthodontic appliances, so that tissue accommodation
and maturation of the newly created bone may occur. After a determined period, it may be
rehabilitated (or removed, if an implant is indicated). A period of time with an acceptable “sa-
fety margin” for bone maturation is 3 months, during which the tooth, and consequently the
periodontium will remain for rehabilitation. On the other hand, if the indication of the treatment
involves extraction and implant replacement, six months would be sufficient. The difference
lies in the fact that, with the removal of the tooth, the periodontium is also extinguished, and
the bone should be completely solidified, to receive the implant with full maturity.
Some authors, such as Brindis & Block,1 consider that the time of extrusion, the inter-
vals between each one and the stabilization period depends directly on the type of bone and
periodontium, that is, on the resistance imposed by the structure.
To illustrate both extrusion techniques, case 6 exhibited tooth #21 with an indication
for retreatment due to the complaint of consistent gingival irritation (Fig. 6 a). Small irregularity
was found within the tooth-prosthesis interface, in a slightly subgingival preparation (Fig. 6b).
The tooth was initially subjected to traction with SOE, for tissue gain (Fig. 6c), envisio-
ning a possible gingival recession inherent to prosthetic preparations. Now with this safety
margin (overcorrection), ROS was carried out, for the subgingival preparation to be exposed
(Fig. 6d-e), leaving the tooth in much more favorable conditions for retreatment. In this last
movement, the gingival height did not change as there was no tissue gain, as a result of the
heavy forces and short intervals.
141
This is a movement performed exclusively with fixed appliances both with rapid ex-
trusion, as well as with the slow extrusion technique. The treatment proposal of sequential
aligners may occur in similar situations, where cervical leveling takes place, when some teeth
are to be repositioned with their cervical height apically inclined. However, when there exists
a necessity to modify the preparation height of gaining gingival tissue for rehabilitation, the
technique of clear aligners has its limitations and is not indicated.
Figure 6c.
Figure 6a.Initial image with the tooth #21 for retreatment.

Figure 6b. Initial periapical X-rays, with evidence of irregularities in the mesial surface of the finishing of the prosthesis.
Figure 6c. Slow orthodontic extrusion, with augmentation of the gingival margin and papillae.
Figures 6d-e. Rapid orthodontic extrusion, with the maintenance of gingival height and exposure of the former preparation.
142
Orthodontics is unquestionably integrated to rehabilitation treatment. Despite being
FINAL CONSIDERATIONS ON
ORTHODONTIC MOVEMENTS
clinically well-founded and supported by the literature, it is underused and in most cases,
not even chosen.
There are two principal situations inwhich rehabilitator does not request the ortho-
dontic therapy. The first and most consistent of which occurs when the existing leveling
allows for an above average finishing of the case and the cost effectiveness of using
braces will be minimal or zero, increasing the time of treatment and the patient’s expendi-
tures unnecessarily. This statement is valid for the most delicate finishings, as are ceramic
veneers and contact lenses, as well as for more invasive preparations, such as prosthetic
crowns.
The second, often unchallengeable reason, is the unwillingness of the patient and/or
rehabilitator themselves to extend the treatment time due to the use of braces. For several
reasons, often involving ignorance with respect to the subject of the urgency of any of the
parties involved to finalize the case, orthodontics is not always regarded as being benefi-
cial. This concept should be principally modified from the perspective of the dentist which
will carry out the planning. When they actually can see and believe in the improvement in
many respects for the patient and for the longevity of the work, the patient will also believe,
with the same intensity as the professional. Some less recurring situations are really res-
trictive, and not should not be argued, such as the financial aspect, functional limitations
of the case and the lack of security or skill of the involved professionals.
For the patient to be involved with the concept of this type of treatment, the choice of
using an appliance is very extremely abrangent, with some exceptions already mentioned.
Today, Orthodontics can reach the various demands of patients particularly in this field of
aesthetics.
The clinical knowledge regarding the various orthodontical proposals has been
growing, but not rarely are the techniques discredited as a result of a lack of information.
Constant updating must be part of clinical life, especially for the rehabilitator, aimed at
producing long-lasting and conservative work with excellence in its completion, directly
proportional to the natural aspect obtained.
The possibility to choose the leveling which enables the orthodontist to offer resour-
ces to the multidisciplinary planning, will circumvent some case limitations. An excellent
example of this is in vertical incisal leveling, which is not a procedure that promotes har-
mony in the gingival area in most of the times, which is usually fundamental for the cons-
truction of the smile. In other words, it is not always the leveling according to the premises
of the aesthetic treatment. However, it is an alternative for minimal harmony when facing
certain restrictions.
In addition to several levellings, focused on conservative tooth reduction proposals
and gingival aesthetics, orthodontic extrusions are also an excellent resource for achieving
naturalness.
The orthodontic forced eruption brings a certain naturality to the completion of the
case. Altough they are relatively simple techniques, they are relentless in their demands.
For the tooth to be rehabilitated, both slow as well as fast extrusion may be used, provided
that the amount of movement to be performed is observed, ie, the amount of root that will
143
remain inserted after completion of the orthodontic therapy must be sufficient enough to
receive the prosthesis lastingly and have its function preserved.
The periodontal biotype is a question that may influence the effectiveness of the
extrusion results. The thinner it is, the greater is the possibility of encountering gingival
recession in more extensive movements. In some cases, it would be of great interest to
begin the therapy using a connective tissue graft for changing this biotype.
In treatments where there is no possibility of minimalistic orthodontics, where requi-
ring a complete orthodontic therapy is needed, extrusion is usually carried out at the be-
ginning of the treatment. This order of priorities is a function of the necessity for accommo-
dation and tissue maturity after manipulation of the periodontal tissues. While maturation
takes place, the rest of the treatment is to be carried out.
The intent of this chapter is merely to clarify and demonstrate to the dentist, in gene-
ral, the range of options that this interaction between specialties may offer. A well-coordi-
nated team with balanced knowledge may reap amazing fruits from this partnership, and
quite often more simply than not.
I can not fail to mention the people who have contributed to my learning in view of
ACKNOWLEDGEMENTS
orthodontic therapy targeted towards cosmetic dentistry and those who have worked in
the clinical cases presented here.
Dr. Bruno Godoy, who, in addition to multidisciplinary planning, excellently conduc-
ted the prosthetic part for completion of case #1.
The oral rehabilitation team of the Oral Atelier Dental Practice, for introducing me to
the search for a minimally invasive dentistry, by way of conducting the rehabilitative phase
of the other cases presented (cases 2 to 6).
144
1. Brindis MA, Block MS. Orthodontic tooth extrusion to enhance soft tissue implant aesthetics. J Oral Maxillofac Surg.
REFERENCES
2009;67(11):49-59.
2. Câmara CALP. Estética em Ortodontia: Parte I. Diagrama de Referências Estéticas Dentais (DRED). R Dental Press Estét.
2004;1(1):40-57.
3. Carinhena GF. Colagem de bráquetes em zênites para o sorriso. In: Carinhena GF. Ortodontia autoligada: mecânicas con-
temporâneas do sistema autoligado passivo. Protocolos de tratamento. São Paulo: Napoleão; 2014. p. 55-95.
4. Fradeani M. Reabilitação estética em prótese fixa: análise estética. São Paulo: Quintessence; 2006.
5. Garber DA. The aesthetic dental implant: letting restoration be the guide. J Am Dent Assoc. 1995;126(3):319-25.
6. Ingber JS. Forced eruption. Part I: A method of treating isolated one and two wall infrabony osseous defects: rationale and
case report. J Periodontol. 1974;45(4):199-206.
7. Janson M. Ortodontia em adultos e tratamento interdisciplinar. 2a ed. Maringá: Dental Press; 2010.
8. Joly JC, Carvalho PFM, Da Silva RC. Reconstrução tecidual estética: procedimentos plásticos e regenerativos periodontais
e peri-implantares. São Paulo: Artes Médicas; 2010.
9. Kyrillos M, Moreira M, Calicchio L. Um olhar cuidadoso sobre a beleza. In: Kyrillos M, Moreira M, Calicchio L. A arquitetura
do sorriso. São Paulo: Quintessence; 2012. p. 69-149.
10. Magne P, Belser U. Restaurações adesivas de porcelana na dentição anterior: uma abordagem biomimética. São Paulo:
Quintessence; 2012.
11. Mantzikos T, Shamus I. Forced eruption and implant site development: soft tissue response. Am J Orthod Dentofacial Or-
thop. 1997;112(6):596-606.
12. Morr T. Improving soft tissue form around implants via forced eruption. Quint Dental Tech. 2005;28:112-28.
13. Pontoriero R, Celenza F Jr, Ricci G, Carnevale G. Rapid extrusion with fiber resection: a combined orthodontic-periodontic
treatment modality. Int J Periodontics Restorative Dent. 1987;7(5):30-43.
14. Romanelli J. Excelência nas finalizações estéticas e periimplantares. In: Callegari A, Dias, RB. Especialidade em foco: beleza
do sorriso. Nova Odessa: Napoleão; 2013. p. 216-45.
15. Romanelli J. O uso do Invisalign® e seu planejamento virtual (ClinCheck®, USA) na adequação de casos para reabilitação
com prepares conservadores. Dicas. 2013;2(4):54-7.
16. Romanelli J. Reabilitações estéticas gengivais compostas pela extrusão ortodôntica. Rev Dental Press Estét. 2014;11(1):46-
59.
17. Salama H, Salama M. The role of orthodontic extrusive remodeling in the enhacement of soft and hard tissue profiles prior
to implant placement: a systematic approach to the management of extraction site defects. Int J Periodont Restor Dent.
1993;13(4):312-34.
18. Salama H, Salama MA, Garber D, Adar P. The interproximal height of bone: a guidepost to predictable aesthetic strategies
and soft tissue contours in anterior tooth replacement. Pract Periodontics Aesthet Dent. 1998;10(9):1131-41; quiz 1142.
19. Scopin de Andrade OS, Kina S, Hirata R. Concepts for an ultraconservative approach to indirect anterior restorations. Quin-
tessence Dent Technol. 2011;34:103-19.
20. Scopin de Andrade OS, Romanini JC, Hirata R. Ultimate ceramic veneers: a laboratory-guided ultraconservative preparation
concept for maximun enamel preservation. Quintessence Dent Techol. 2012;35:29-42.
21. Smallwood TW. Invisalign and porecelain: the contemporary restorative powerhouse. J Orofac Alpha Omegan.
2009;102(4):148-51.
22. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or
absence of the interproximal dental papilla. J Periodontol. 1992.;63(12):995-6.
145
chapter 5.2
periodontal plastic surgery
Rafael de Almeida Decurcio | Amin de Macedo Mamede Sulaimen | Leandro de Carvalho Cardoso
The overwhelming evolution of Aesthetic Dentistry is accompanied by the relevant
appreciation of interdisciplinary works. Today, it is unthinkable to treat patients within a sin-
gle discipline, shortsighted, without proposing at least a broad overview of the real possi-
bilities of treatment. In the realm of aesthetic restorations, perio-implant dentistry is a major
player, from the evaluation of the aesthetic principles of gingiva and their convergences,
to actions aimed at the optimization of the results. Also on multidisciplinarity, periodontics
and implant dentistry have merged, to act on similar problems, inwhich what was merely
changed is the substrate, teeth or implants. In this manner, rehabilitative interventions must
necessarily be proposed after a thoughtful and planned periodontal-implant intervention,
either by pragmatic prevention of diseases and consequent promotion of the longevity of
the treatments performed, or by the application of surgical techniques that aim to improve
the current clinical condition and optimization of the proposed aesthetic results.
With the understanding that the ceramic veneers are part of the treatments per-
PERIODONTAL BIOTYPE
formed at the end of the rehabilitation process and that infectious and/or periodontal in-
flammatory lesions should undergo previous intervention, the entire approach in this chap-
ter will be in treating discrepancies as opposed to ideal periodontal aesthetic principles.
For this, knowledge of the periodontal biotype becomes essential to the understanding
of the processes related to the individualization of the surgical therapies proposed for the
regularization of implant-aesthetic periodontal discrepancies.20
Although there are reports in the literature on the subdivision of the periodontal biotype
into three conditions,32 it is wiser to subdivide it into two types, keeping in mind that the inter-
mediate periodontal biotype at times suffers from misguided interventions due to diagnostic
errors, which leads to unsatisfactory results, so it should always be considered thin.4
Kan & cols22 demonstrated that the observation from the probing of the gingival sul-
cus is a safe an accurate method of identifying the periodontal biotype. When the lines of
the periodontal probe were not visible in the gingival sulcus, it was identified as having a
thick biotype and, when visible, it was said to be thin.
Given the difficulty and subjectivity of the evaluations and different techniques to
define the type of periodontal biotype, didactically, the authors adopt the pattern set by
Olsson and Lindhe,36 that is, the periodontal biotype is divided into two types (Table 1):
1. flat and thick: presenting a wide range of keratinized mucosa, with dense, fibrous
tissue, short and wide papillae, and underlying flat and thick bone; and
2. thin and scalloped: featuring a small strip of keratinized tissue, thin tissue, with long,
narrow papillae and thin and scalloped underlying bone.36
These periodontal biotypes and their antagonistic features provide clinical explana-
tions of the discrepancies presented, that hinder the aesthetic results of the rehabilitation
proposals. Similarly, they offer clear conditions towards the individualization of the surgical
treatment and predictability over the implemented therapies.39
148
According to their morphological characteristics, thick biotypes are associated with
flat and short gingival papillae and square-shaped teeth.36 (Fig. 1a-f) Such a condition be-
comes relevant when establishing a new and different dental format for a rehabilitation pro-
posal, confering antagonism to the gingival and dental morphologies. Surgical intervention
should invariably follow the pattern of the established dental form; that being, the mock-up
has an essential role in this step. When a squared tooth shape is chosen, the periodontal
biotype may remain slightly thicker, with flat and short papillae and bulkier marginal tissue
without any loss of naturality to the result.
Figure 1. Patient with thick periodontal biotype from the initial smile photography (a) with separated lips (b). Photography after periodontal surgery guided by the mock-up matching the final gingival
contour obtained (c). After rehabilitation, final photographs of the patient with lips apart in occlusion (d) and with the black background (e) displaying the final gingival contour obtained, along with the final
smile photograph showing the resolution of the gingival smile and achieved harmony (f).
149
In clinical situations in which the periodontal biotype is too thick (Fig. 2a-u), establishing an ovoid-shaped tooth or
mainly triangular requires greater invasive surgical interventions. This occurs in cases of clinical crown tissue lenghtening
with a more extensive removal of volume, especially osseous, and a new contour of the coronal marginal bone, to offer an
aspect of a smoother transition between the parts of the rehabilitation, gingiva and tooth. By analogy, in cases of gingival
recession, the natural maintenance or rehabilitative establishment of squared teeth impose the need for the surgical incor-
Figure 2c.
Figure 2a. Figure 2b. Figure 2d.
Figure 2h. Figure 2k. Figure 2l.
Figure 2. Case of patient with thick biotype. Initial photographs of the face: frontal smile (a) and lateral smile (b).Close-up initial mouth: Frontal smile (c), frontal at rest (d), lateral smile (e-f) and initial upper
arch (g). Photographs of periodontal surgery: acrylic indirect mock-up in place as a lengthening guide (h), flap raise-up (i) flap detached (j) and bur in place to perform the osteotomy (k). Photographs after
clinical crown lengthening: close-up of smile (l), frontal face with smile (m) and lateral (n). After periodontal surgery were performed the preparations, impressioning and making of the ceramic veneers.
Detail of the ceramic veneers on the stone model (o). Final photographs of the patient with the cemented veneers: Frontal with lips at rest (p), dentolabial frontal smile (q) and laterals (r-s), and face with
frontal smile (t) and lateral (u).
150
poration of a higher volume of marginal tissue compared to ovoid or triangular shaped teeth. Another condition of enormous
relevance in relation to thick biotypes is the beneficial sum of their morphological characteristics to the rehabilitation. Volumi-
nous, fibrous tissue, consequently less transparent,22 favors subgingival prosthetic preparations, as well as the positioning
of ceramic veneers at the same level. This becomes critical with dark coronary or root substrates requiring greater coronal
reduction or a superior ability of masking the darkened cervical margin.
Figure 2o.
Figure 2m. Figure 2n. Figure 2p.
Figure 2q. Figure 2r. Figure 2s.
Figure 2t. Figure 2u.
151
Recent studies adopting the cone-beam computerized tomography have confirmed a positive correlation between
facial soft tissue thickness and bone lamina.10,13 In other words, a thick periodontal biotype is associated with a thicker
lamina bone labial.10
Thin periodontal biotypes are associated with long, narrow papillae and triangular-shaped teeth.36 In this biotype the
analytical concept is the inverse of that which was previously presented. Surgical interventions must be thoroughly careful
due to the thin and delicate thickness of the gingival tissue and the constant presence of scalloped areas of bone tissue,
that produce disastrous results when handled without their due parsimony. In contrast, surgical interventions for clinical
crown lengthening and dimensional readjustments for ceramic restorations allow for conservative access without flap lifting,
known as the flapless technique.5,21 (Fig. 3a-d)
Another highly relevant factor for the thin biotype is the transparency of the marginal tissue,22 which presents the
undesireable chromatic conditions of the root browning cyanotic halo of the metal margin of restorations, cementation
lines and others. The analysis of these situations is of fundamental importance to the establishment of the rehabilitation
processes,considering that a thin biotype requires the carrying out of preparations and/or ceramic supragingival positioning
or at least, at the level of the gingival margin. Sometimes surgical interventions for readjusting the marginal tissue volume
are necessary to avoid aesthetically satisfactory ceramic results accompanyed by aesthetically unpleasant gingival results,
either through maintenance of the marginal darkening, or by the appearance of gingival recession due to the thickness of
the gingival tissue.26
Figure 3. Case of patient with thin biotype. Initial intraoral photograph of the patient with gingival recession (a) and photo after connective graft within the region of the canines (b). Close-up photo of the
central incisors evidence of the long, narrow papilla and the triangular teeth, characteristic of this biotype (c). Photo after the cementation of the veneers showing the harmony of the gingival contour
obtained in patients with thin biotype(d).
152
Table 1. Periodontal biotype.20
PLAN AND THICK FINE AND SCALLOPED
Dense and fibrotic soft tissue Thin soft tissue
Broad range of keratinized tissue Reduced range of keratinized tissue
Short and wide papillae Long and narrow papillae
Thick, flat underlying bone Thin and scalloped underlying bone (high frequency of dehiscence and fenestration)
Attachment loss associated with the presence of periodontal pocket Attachment loss associated with the presence of recession of the gingival margin
Contact area in the middle/cervical third Contact point in the incisal/occlusal third
Square-shaped teeth Triangular-shaped teeth
GINGIVAL As described in Chapter 2, ideally, an aesthetically pleasing gingival contour occurs

RECONTOURING when the gingival zenith of the maxillary central incisor is vertically symmetrical to the ca-
nine and when it ranges from 0.5 mm to 1.5 mm more apically to the lateral incisor. In this
conformation, the zenith positions of anterior superior teeth are characterized as the verti-
ces of an imaginary triangle with its base towards the apical, which confirms the balance
of the gingival components. The absence of this harmony, verified by the absence of the
imaginary formation or the inversion of this triangle, suggests the surgical correction of this
tissue contour for optimization of the aesthetic result. (Fig. 4a-h)
Figure 4. Case of patient operated by the flapless technique, initial intraoral photography in occlusion (a) and of Illustration of the development of the technique: preparation of the direct composite resin
mock-up (b-d) and its use as a surgical guide for the clinical crown lenghtening (e-f). Photo immediately after surgery (h)and after healing and cementation of the veneers(i).
153
The presence of a high smile line and disharmonic gingival contours suggests to the
clinician the need for cosmetic periodontal surgery. However, surgical interventions are
dependent upon the patient’s desire, and do not always carried out according to the case
presented. (Fig. 5a-e)
Figure 5. Patients demonstrating a high smile line and disharmonious gingival contour (c). Frontal view of the veneer of tooth #11 completed without surgical intervention (d-e). Dental technician: Murilo
Calgaro.
Gingival recession is defined as the apical migration of the gingival margin in relation to
GINGIVAL
COVERAGE
the cement-enamel junction (CEJ).47 According to Baker & Seymour,3 the etiology of these
lesions is accompanied by inflammation produced by the accumulation of biofilm or too-
thbrushing trauma, found in populations with both a high as well as a low oral hygiene index.
Undoubtedly, the presence of gingival recession makes a smile less attractive and
frequently the complaint of patients. However, it may also be associated with functional
problems such as cervical hypersensitivity, as well as carious and noncarious cervical
lesions, and a greater likelihood of biofilm accumulation.35
There are several techniques with the purpose of root surface coverage, the predic-
tability of which is primarily associated to the proximal bone height.30 Other factors such
as the amount of keratinized gingiva, gingival thickness, presence/absence of cervical
lesions, height and width of the papillae, may influence the most appropriate technique
decision for the coverage of exposed roots.43
154
Gingival recessions are more prevalent in thin biotypes than in thick biotypes; thus surgical interventions are often
associated to the replacement of areas of tissue lost by the installation of infectious and/or traumatic inflammatory proces-
ses.1
The aesthetic planning of clinical conditions that involve the presence of gingival recession depends on integrating
periodontal and restorative concepts for achieving harmonious results. In these situations, the restorative planning is critical
to establishing the optimal positioning of the future prosthetic margin, prior to the surgical procedure.48 Regardless of the te-
chnique used, the clinical success of the coverage is defined by the complete coverage of the root surface, with a probing
depth of less than 3 mm, absence of gingival inflammation, and tissue volume and coloration compatible with the adjacent
areas, so that the treated region is indistinguishable from other regions that do not present recessions.28 (Figures 6a-x)
Figure 6. High smile line revealing gingival disharmony (a). Intraoral view showing gingival recession of the tooth 13 and changed positions of the gingival zenith in teeth #11 and #12 (b). Determining the
lengths of the clinical crowns of the six anterior teeth with a millimeter probe (c-h). Delimitation of the new gingival zenith outline #15c scalpel blade (i). Detail of the gingival collar to be removed of teeth
#11 and #12 (j). Scaling and planning for disinfection and for adequation of volume for later adaptation of the graft on tooth #13 (p). Suture with tensioning of the gingival tissue towards the coronal
aspect (s). Intraoral aspect after cementation of full ceramic “contact lenses” veneers without preparation with feldspathic porcelain (see chapter 5.3) (v) and the final smile (x).
155
Figure 6j. Figure 6k. Figure 6l.
Figure 6m. Figure 6n. Figure 6o.
Figure 6p. Figure 6q. Figure 6r.
Figure 6s. Figure 6t. Figure 6u.
Figure 6v. Figure 6x.
156
According to Joly, De Carvalho & Da Silva,20 surgical interventions of clinical crown
AESTHETIC CLINICAL
CROWN LENGTHENING
lengthening (osteotomy/osteoplasty procedures ) for the thick biotype are dependent
upon flap elevation for exposure of the bone crest, since osteoplasty (bone removal in
thickness) is necessary to optimize bone architecture and improve the adaptation of the
soft tissue in the cervical region. (Table 2) In such cases, and in conjunction with restora-
tive procedures, the healing time, which typically ranges from 90 to 180 days, should be
strictly respected for the proper maturation of the cervical soft tissues. However, depen-
ding upon the extent of the periodontal surgery, it can reach up to one year.42 (Fig. 7 e 8)
When there is no related restorative treatment, the osteotomy limit is determined by the
location of the CEJ, so that there is no undesireable exposure of the root portions, which
may generate deleterious clinical consequences, such as dentin hypersensitivity and non-
carious cervical lesions.
In the case of thin and intermediate biotypes, the osteoplasty may be dismissed
depending upon the delicate thickness of the natural bone, and osteotomy should be
performed exclusively with manual instruments. With the use of the appropriate micro-chi-
sels able to be introduced into the gingival sulcus without trauma to the soft tissue, flap
elevation may be disregarded, which is known as the flapless technique. Considering the
impossibility of the direct visualization of the extent of the osteotomy, periodontal probing
becomes critical before, during and after the surgery, to confer the reestablishment of the
biological width.20 (Table 2) (Fig. 7 e 8)
Table 2. Comparisons between two augmentation techniques of aesthetic clinical crowns.

FLAPLESS CONVENTIONAL
IINDICATION Fine and intermediate Biotypes Thick biotypes
SUTURES Absent Present
DISCOMFORT AFTER SURGERY Minimal Moderate
VISUAL ASPECT OF THE CICATRIZATION Fast Slow
SURGICAL TIME Short Long
SURGICAL TECHNIQUE Meticulous and delicate Large and conventional
OSTEOTOMY Small Medium to high
Either by predominantly periodontal motivation, or in association to restorative pro-

cedures, aesthetic clinical crown lenghtening must be exhaustively discussed with the
patient, for safe decision-making, given the nature of this definitive procedure. Again, the
direct or indirect restorative trial starts with this decision-making process, providing early
and provisionally the new tooth dimensions of the proposed rehabilitation.
157
Figure 7c.
Figure 7h. Figure 7i. Figure 7j.
Figure 7k. Figure 7l.
Figure 7. Frontal facial and initial profile analysis (a-b). Lack of maxillary teeth exposure at rest (c). Initial smile revealing the presence of multiple diastemata, gingival exposure greater than 3 mm in the
posterior region, lack of parallelism between the incisal line and the line passing through the lower lip and reverse incisal curve (d). Initial upper and lower intraoral photographs identifying a thick “classic”
biotype in the posterior region (Table 2) and the presence of short papillae (e-l). Determining the distance Interpupillary and confirmation of ideal measures in the mock-up (m-n). Mock-up in position
guiding the incision of the new gingival contour (o). Detail of the gingival collar after the removal of the mock-up at the right side (p). Appearance after complete removal of the mock-up (q). Protocol
sequence of the removal of the gingival collar with appropriate curettes (r-v).
158
Figure 7n. Figure 7o.
Figure 7m. Figure 7p. Figure 7q.
Figure 7r. Figure 7s. Figure 7t.
Figure 7u. Figure 7v. Figure 8a.
Figure 8b. Figure 8c.
Figure 8. Positioning of the millimeter probe before the osteotomy (a-b). Osteotomy with microchisels by the flapless technique (c). Verification of the amount of bone removal with millimeter probe (d).
Flap raise-up in the posterior region (e). Positioning of the diamond point to perform osteoplasty (f). Appearance after bone volume reduction (g). Suture limited to the area which was submitted to the flap
raise-up (h). 120 days after healing and packing of the first retraction cord for impression (i). Intraoral and smile photographs immediately after cementation of the prepless maxillary ceramic veneers (j-k).
Cementation sequence of mandibular ceramic veneers with minimal tooth reduction (l-q). Final intraoral, smile and facial appearance (r-t).
159
Figure 8p. Figure 8q.
Figure 8r. Figure 8s.
160
Figure 8t.
161
Excessive maxillary gingival exposure is commonly referred to as a gingival smile. However, often, the gingival smile
GINGIVAL SMILE
is confused with a high smile line. All patients who possess gingival smile present high smile line, although the opposite is
not true, since the gingival smile is represented by an exposition of the gingiva greater than 3 mm (Fig. 9) Several treatment
options are available for correcting the gingival smile,24 the best of which is based on the etiology.
Dentoalveolar extrusion of the maxillary incisors leads the gingival margin towards a more coronal position and causes
EXCESSIVE
EXPOSURE OF
TOOTH AND GINGIVA
INCREASED
NORMAL EXPOSURE
EXPOSURE OF
OF INCISIVE DURING
INCISIVE DURING
REST
REST
NORMAL LIP SHORT SHOR CLINICAL NORMAL LENGTH

LENGTH SUPERIOR LIP CROWN OF CLINICAL
CROWN
DIFFERENCE BETWEEN
THE HARMONY OF
HARMONIOUS HIPERACTIVE
THE ANTERIOR AND INCISAL WEAR WITHOUT WEAR
OCLUSAL PLAN SUPERIOR LIPS
POSTERIOR OCLUSAL
PLANES
VERTICAL ALTERED PASSIVE

EXTRUSION EXTRUSION GINGIVAL
MAXILLARY ERUPTION
OF INCISIVES OF INCISIVE HYPERPLASIA
EXCESS (VME) (1 OR MORE TEETH)
Quadro 1. Schematic drawing of the treatment options of the gingival smile according to clinical characteristics.
Figure 9c.
Figure 9. Initial protocol photographs, smile and rest, revealing the presence of gingival smile, optimal exposure at rest and lingual inclination of anterior superior teeth (a-f). Incision of the new gingival
contour guided by the mock-up with the ideal dimensions (g). Detachment of the gingival collar with a curette (h). view of flap raise-up (i). Detail of the repositioning of mock-up and and millimeter probe
for evaluating the amount of tissue removed (j). Intraoral appearance after 120 days of clinical crown lengthening (k). Packing of retraction cords for impressioning and future manufacture of prepless
ceramic veneers (l-n). Intraoral view after cementation of the ceramic veneers (o-p). Final smile (q). Final appearance of profile smile, detail of increased buccal volume after cementation (r) and final
protocol (s) and artistic photographs (t-u). Dental technician: José Carlos Romanini.
162
Figure 9h. Figure 9i. Figure 9j.
Figure 9k. Figure 9l. Figure 9m.
Figure 9n. Figure 9o. Figure 9p.
Figure 9q.
163
Figure 9t.
Fotografia realizada por Dudu Medeiros.
164
Figure 9u.
Fotografia realizada por Dudu Medeiros.
165
excessive gingival exposure, this condition could possibly be associated with wear of the
anterior teeth or an overbite. In the latter case, there is discrepancy between the occlusal
plane of the anterior and posterior segments.The orthodontic intrusion of the elements
involved, moving the gingival margin more apically, the periodontal surgical correction,
with or without adjunctive restorative therapy, or an interdisciplinary intervention are the
treatment options for this condition.6,12,15
Excessive growth of the maxilla in the vertical direction may lead to the association
of the Elongated Face Syndrome.23,7 (Fig. 10) This increase occurs in the lower third of the
face, and, unlike the extrusion of the maxillary incisors, there is no discrepancy between
the occlusal plane of the anterior and posterior segments. Excessive gingival exposure in
these cases occurs due to the presence of an occlusal plane relatively below the normal
pattern, causing the lower lip to cover the edge of the incisors, canines and premolars.
Figure 9u.
Photograph byFigure
Dudu10.
Medeiros.
Figure 10. Gingival smile caused by excessive growth of the maxilla in the vertical direction.
166
Regarding the upper lip, described in Chapter 2, with proportions lower than the
default measure, the treatment options are plastic surgery, such as the elongation of the
upper lip which is associated with rhinoplasty.24,29 In the cases of hyperactivity of the
muscles responsible for the lip movement while smiling, some cosmetic procedures are
available, such as silicone implantation in the vestibule bottom, surgical procedures in the
muscles responsible for the upper lip mobility, and bioplasty, where polymethylmethacryla-
te is applied into the tissues.
These two techniques were based on the same concept of incising the elevator
muscle of the upper lip, or part thereof (the main muscle involved with the formation of the
smile). According to the author, this procedure results in decreased elevation of the upper
lip during smile.37
Recently, the application of botulinum toxin has been suggested for the treatment of
hypermobility of the upper lip.40 Botulinum toxin is a simple, fast and effective method for
cosmetic correction of the gingival smile. Mazzuco & cols27 cited other factors that consi-
der the toxin as a first-line therapy, for its ease and safety during application, as well as its
quick action, low risk and reversible effect. This ultimate factor is particularly interesting in
cases where the orthodontic treatment or surgical procedure is recommended, by way of
allowing the aesthetic effect prior to the invasive procedure.
The emergence profile of the tooth is determined by the exit of the crown from the
bone crest, which is considered completed when the tooth reaches the occlusal plane
and enters into function. Associated with dental eruption, the soft tissues accompany this
movement, and at the end of this process, the gingival margin migrates apically until it is
located close to the CEJ (passive eruption). When the gingiva does not return to its original
position, it earns its given name “altered passive eruption”. According to Isiksal,19 a short
clinical crown and gingival excess are consequences of an altered or delayed passive
irruption, which hampers the proper recession of the gingival tissue at the level of the CEJ.
This condition has been classified into types and subcategories. The type indicates the
amount of attached gingiva, and the subcategory, the relationship of the bone crest to the
CEJ.
In cases of passive eruption in the presence of excess soft tissue and bone tissue,
the surgical approaches indicated are the conventional clinical crown lenghtening or the
flapless techniques.21 When the aesthetic change of the smile is caused by increased
vertical maxillary growth, various techniques can be recommended, from orthodontic in-
trusion to orthognathic surgery, but always giving priority to the aesthetic clinical crown
lengthening and possible involvement with complementary restorative procedures.
However, it is up to the patient to define the surgical option utilizing the mock-up as
a facilitating tool in this decision-making process.The exclusion of orthognathic surgery as
first choice stimulates the indication of a second option, which involves performing perio-
dontal cosmetic surgery associated with ceramic laminates, which have proven satisfac-
tory results even when facing limitations and difficulty in obtaining the optimal resolution.2
(Fig. 2) In such cases, some procedures, such as botulin toxin infiltration, are available
which can supplement the actions for the treatment.17,34, 37,40,41
167
The evolution of bioengineering, the technical and scientific advances and the incre-
IMPLANT IN THE
AESTHETIC ZONE
ased use of osseointegrated dental implants in totally or partially edentulous patients pro-
vided aesthetic advances in implant-supported rehabilitations, which has become a key
factor in the success of implantology. Thus, some procedures, such as planning based
on aesthetic fundamentals, set out in Chapter 2, the wax-up and mock-up, described in
Chapter 3, and the production of radiographic and surgical guides have become manda-
tory, since the implant positioning is to be determined mainly by the future rehabilitation, ra-
ther than the conditions of the bone at the receiving site.16
From an aesthetic point of view, the presence of a suitable band of keratinized muco-
sa, combined with suitable gingival thickness prior to the implant installation, it is of para-
mount importance for the aesthetic result and longevity of the treatment, being that thicker
gingival tissues certainly present better aesthetic results than thin gingival biotypes. The
absence of this condition may involve difficult cleaning, greater accumulation of plaque,
peri-implant gingival inflammation, gingival dehiscence with the simultaneous appearance
of the metal of the implant and discrepancy of the apparent size of the homologous teeth.44
By analogy, even in immediate rehabilitating conditions, the effect of the transillumi-
nation of the metallic part of the implant may also occur due to the presence of fairly thin
tissue which becomes aesthetically displeasing in the smile composition. This problem
results from the gingival tissue being of an inadequate thickness or from a more apical
positioning of the attachment level of the connective and bone tissues around the implant.
The appearance of gingival “black holes” is another aesthetic problem which can
result from the lack of keratinized tissue. It is about the absence of adequate papillary
tissue at the gingival margin between the teeth, between teeth and implants, and between
implants in the anterior segment. In addition to the need for the existence of keratinized
tissue in quantity and quality, the correct positioning of implants in the edentulous space
and respect for the distances (vertical and horizontal) between implants and teeth which is
essential for maintaining the shape of the papillae.
Grunder18 found that a distance of 5 mm between the contact point and the bone
crest is required when an implant is placed adjacent to a tooth, for the complete filling of
the papillary space to occur, similar to that which was already known about the distance
between teeth.This study also postulated that the vertical positioning of the implant does
not establish success in the process of the formation of the papilla, a factot later confirmed
by Choquet et al.8
The difficulty in creating the papilla appears to be higher among implants, mainly
whithin the aesthetic areas.14,15 Tarnow & cols46 have shown that the distance between
two implants should be at least 3 mm. However, this distance between implants does not
guarantee the formation of the papilla, it merely prevents further inter-implant bone loss.
In another clinical study, Tarnow & cols45 found that a 2 mm to 4 mm height (average 3.4
mm) of soft tissue may be expected to cover the inter-implant crestal bone, a situation that
should be considered in aesthetic regions when planning.
There is concern about the optimal maintenance of the biological space and its
clinical effects on peri-implant aesthetics. For teeth that have a cavity preparation and
consequently the margin of the restoration is very close to the crestal bone, not respecting
168
the structures of the biologic width, insertion loss due to the inflammatory process takes
place, triggered by the invasion of the biologic width. For implants, especially in aesthe-
tic areas, where is required to place the platform at the level of the crest, loss of bone
structure also occurs, in order to establish an adaptation of the structures that form the
biologic width around implants.9 Thus, although the loss of bone that takes place around
implants may be considered natural, it should be controlled and well understood, as the
final aesthetic result will depend in a good part on the understanding of this phenomenon.
It is important to be aware that this loss occurs threedimensionally, around 1 mm to 1.5
mm, and that the remaining bone should exist around the entire implant after the formation
of the biologic width. If it does not occur, severe aesthetic problems may arise.
The preliminary approach to the installation of implants includes the use of surgical
guides which includes the mock-up. (Fig. 11a-x) Beyond that, when the elaboration of
the treatment plan is needed for implant placement in areas with compromised dental
elements is included, the professional must then pressupose the presence of bone and/
or gingival deformities. Whenever possible, the professional must focus their efforts on
tissue preservation and prevention of possible defects, but, when they are present and
they compromise the installation of the implants, reconstructive procedures should be
performed prior to or at the moment of extraction.33
Figure 11.Initial facial analysis (a-c). Initial smile revealing the absence of lateral incisors, presence of deciduous canines and a posterior gingival smile (d). Initial intraoral aspect (e). Mock-up installed (f).
Mock-up positioned guiding the incision for clinical crown lengthening (g). Aspect after the initial incision (h). Extraction of primary canines #53 and #63. (i).
Positioning of the mock-up for guide pin installation (j). Using the countersink for proper adaptation of the implant in the cervical portion (k). Installation of the implant (l).Frontal and incisal view after
installation of zirconia abutments (m-n). Smile after installation of provisional crowns (o-p).Appearance after preparation of canines (q). Veneers and crowns finalized and placed on the stone model (r).
Final intraoral aspect (s). Final photographic protocol (t-v). Photographs by Dudu Medeiros.
169
170
Figure 11p. Figure 11q.
Figure 11t.
171
Figure 11u.
172
Figure 11v.
173
In addition to proper planning and observation of the possible necessity of bone as well as gingival tissue adjust-
ments, the surgical technique for implant installation is critical to the aesthetic success of the case.
Aesthetic areas, namely the anterior maxillary area, requires a different surgical approach. The incision should avoid
the area of the papillae, because it is a critical area, beyond being directed by the distance between the contact point and
the bone, the healing process may be compromised.25 (Fig. 12a-x)
Figure 12. Initial smile revealing absence of the lateral incisor and the presence of diastemas (a). Initial intraoral aspect (b-e). Aspect of the area to be implanted after removal of the prosthesis (f). Aspect of
the incision (g-i). Osteotomy with micro-chisels by the flapless technique (j). Circular incision with a scalpel (k). Drilling of the bone (l). Installed implant (Nobel Active®, Nobel Biocare) (m). Aspect after the
installation of the provisional crown (n). Intraoral view after healing and subepithelial gingival graft on tooth #22 (o). Final intraoral aspect (p). Final photographic protocol (q-r).
174
Figure 12m. Figure 12n.
Figure 12o. Figure 12p.
Figure 12q. Figure 12r.
175
1. American Academy of Periodontology. Glossary of Periodontal Terms. 4rd ed. Chicago: The American Academy of Perio-
REFERENCES
dontology; 2001.
2. Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning. Part II. Am J Orthod Dentofacial Or-
thop. 1993 May;103(5):395-411.
3. Baker DL, Seymour GJ. The possible pathogenesis of gingival recession: a histological study of induced recession in the rat.
J Clin Periodontol. 1976;3:208-219.
4. Caplanis N, Lozada JL, Kan JY. Extraction defect assessment, classification, and management. J Calif Dent Assoc. 2005
Nov;33(11):853-63.
5. Carvalho PFM, Silva RC, Joly JC. Aumento de coroa clínica estético sem retalho: uma nova alternativa terapêutica. Rev
Assoc Paul Cir Dent. 2010;ED ESP(1):26-33.
6. Chiche GJ, Pinault A. Aesthetics of anterior fixed prosthodontics. Chicago: Quintessence; 1994.
7. Chiche GJ, Pinault A. Replacement of deficient crowns. J Esthet Dent. 1993;5(5):193-9.
8. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and radiographic evaluation of the
papilla level adjacent to single-tooth dental implants: a retrospective study in the maxillary anterior region. J Periodontol. 2001
Oct;72(10):1364-71.
9. Cochran DL, Hermann JS, Schenk RK, Higginbottom FL, Buser D. Biologic width around titaniun implants: a histometric
analysis of the implanto-gingival junction around unloaded and loaded non submerged implants in the canine mandible. J
Periodontol. 1997;68:186-98.
10. Cook DR, Mealey BL, Verrett RG, Mills MP, Noujeim ME, Lasho DJ, et al. Relationship between clinical periodontal biotype
and labial plate thickness: an in vivo study. Int J Periodontics Restorative Dent. 2011;31(4):345-54.
11. Fradeani M. Estethic analysis: a systematic approach to prosthetic treatment. Chicago: Quintessence; 2004.
12. Fradeani M. Aesthetic rehabilitation in fixed prosthodontics. Chicago: Quintessence; 2004.
13. Fu JH, Yeh CY, Chan HL, Tatarakis N, Leong DJ, Wang HL. Tissue biotype and its relation to the underlying bone morphology.
J Periodontol. 2010;81(4):569-74.
14. Garber DA, Salama MA. The aesthetic smile: diagnosis and treatment. Periodontol 2000. 1996;11:18-28.
15. Garber DA, Salama MA, Salama H. Immediate total tooth replacement. Compend Contin Educ Dent. 2001 Mar;22(3):210-6,
218.
16. Garber DA. The aesthetic dental implant: letting restoration be the guide. J Am Dent Assoc. 1995 Mar;126(3):319-25.
17. Gracco A, Tracey S. Botox and the gummy smile. Prog Orthod. 2010;11(1):76-82.
18. Grunder U. Stability of the mucosal topography around single-tooth implants and adjacent teeth: 1-year results. Int J Perio-
dontics Restorative Dent. 2000 Feb;20(1):11-7.
19. Işiksal E, Hazar S, Akyalçin S. Smile aesthetics: perception and comparison of treated and untreated smiles. Am J Orthod
Dentofacial Orthop. 2006 Jan;129(1):8-16.
20. Joly JC, Da Silva RC, Carvalho PFM. Reconstrução Tecidual Estética: procedimentos plásticos e regenerativos periodontais
e peri-implantares. São Paulo: Artes Médicas; 2009.
21. Joly JC, Da Silva RC, De Carvalho PFM. Reconstrução tecidual estética: procedimentos plásticos e regenerativos. São
Paulo: Artes Médicas; 2010.
22. Kan JY, Morimoto T, Rungcharassaeng K, Roe P, Smith DH. Gingival biotype assessment in the aesthetic zone: visual versus
direct measurement. Int J Periodontics Restorative Dent 2010;30(3):237-43.
23. Kawamoto HK Jr. Treatment of the elongated lower face and the gummy smile. Clin Plast Surg. 1982;9: 479-89.
24. Levine RA, McGuire M. The diagnosis and treatment of the gummy smile. Compend Contin Educ Dent. 1997;18(8):757-
62~764.
25. Lorenzana ER, Allen EP. The single-incision palatal harvest technique: a strategy for aesthetics and patient comfort. Int J
Periodontics Restorative Dent. 2000 Jun;20(3):297-305.
26. Maynard JG Jr, Wilson RD. Physiologic dimensions of the periodontium significant to the restorative dentist. J Periodontol.
1979 Apr;50(4):170-4.
27. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: a new approach based on the gingival esposure area. J Am Acad
Dermatol. 2010;63(6):1042-51.
28. Miller PD Jr. Periodontal plastic surgical techniques for regeneration. In: Polson AL. Periodontal regeneration-current status
and directions. Chicago: Quintessence; 1994. p. 53-70.
29. Miskinyar SA. A new method for correcting a gummy smile. Plast Reconstr Surg. 1983;72:397-400.
30. Modica F1, Del Pizzo M, Roccuzzo M, Romagnoli R. Coronally advanced flap for the treatment of buccal gingival recessions
with and without enamel matrix derivate: a splith-mouth study. Periodontol 2000. 2000;71(11):1693-8.
31. Morley J, Eubank J. Macroaesthetic elements of smile design. J Am Dent Assoc. 2001;132(1):39-45.
32. Müller HP, Könönen E. Variance components of gingival thickness. J Periodontal Res. 2005 Jun;40(3):239-44.
33. Nemcovsky CE, Moses O, Artzi Z. Interproximal papillae reconstruction in maxillary implants. J Periodontol 2000
Feb;71(2):308-14.
34. Niamtu J 3rd. Botox injections for gummy smiles. Am J Orthod Dentofacial Orthop. 2008 Jun;133(6):782-3; author reply
783-4.
35. Novaes AB, Novaes Jr AB. Cirurgia periodontal com finalidade protética. São Paulo: Artes Médicas; 1999.
36. Olsson M, Lindhe J. Periodontal characteristics in individuals with varying form of the upper central incisors. J Clin Periodon-
tol. 1991 Jan;18(1):78-82.
37. Peck S, Peck L, Kataja M. Some vertical lineaments of lip position. Am J Orthod Dentofacial Orthop. 1992 Jun;101(6):519-24
38. Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod 1992 Summer;62:91- 100; discussion 101-2.
39. Polack MA, Mahn DH. Biotype change for the aesthetic rehabilitation of the smile. J Esthet Restor Dent. 2013 Jun;25(3):177-
86.
40. Polo M. Botulinum toxin type A (Botox) for the neuromuscular correction of excessive gingival display on smiling (gummy
smile). Am J Orthod Dentofacial Orthop. 2008 Feb;133(2):195-203.
176
41. Polo M. Botulinum toxin type A in the treatment of excessive gingival display. Am J Orthod Dentofacial Orthop. 2005
Feb;127(2):214-8; quiz 261.
42. Pontoriero R, Carnevale G. Surgical crown lengthening: a 12-month clinical wound healing study. J Periodontol. 2001;72:841-
8.
43. Silva CO, Ribeiro-Júnior NV, Campos TV, Rodrigues JG, Tatakis DN. Excessive gingival display: treatment by a modified lip
repositioning technique. J Clin Periodontol. 2013 Mar;40(3):260-5.
44. Strub JR, Gaberthüel TW, Grunder U. The role of attached gingiva in the health of peri-implant tissue in dogs. 1. Clinical
findings. Int J Periodontics Restorative Dent. 1991;11(4):317-33.
45. Tarnow D, Elian N, Fletcher P, Froum S, Magner A, Cho SC, et al. Vertical distance from the crest of bone to the height of the
interproximal papilla between adjacent implants. J Periodontol. 2003 Dec;74(12):1785-8.
46. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontol.
2000 Apr;71(4):546-9.
47. Wennström JL. Mucogengival therapy. Ann Periodontol. 1996;1:671-701.
48. Zucchelli G, Testori T, De Sanctis M. Clinical and anatomical factors limiting treatment outcomes of gingival recession: a new
method to predetermine the line of root coverage. J Periodontol. 2006 Apr;77(4):714-21.
177
chapter 5.3
tooth bleaching
Jussara Bernardon | Rafael Decurcio | Paula de Carvalho Cardoso
Tooth bleaching is one of the most performed daily clinical procedures.7 Regarded
as a prerequisite for aesthetic dentistry, especially when associated with treatments that
require changes in smile architecture.5,39 For direct and indirect restorative treatments to
be started, it is necessary that the patient is satisfied with the color of their natural teeth
because it will remain in the “new” tooth arrangement. Such importance is due to the in-
fluence of the substrate color when ultrafine ceramic veneers are indicated2 or when you
need to modify the tooth form, through the use of composite resin in specific locations
of the crown, towards the improvement of the harmony of the smile. In other words, it is
essential to obtain the shade desired by the patient for the teeth to be restored as well
as for the teeth which will remain without restorations, before carrying out the restorative
treatment. Shade matching of all substrates involved in this process is a condition which
is part of the rehabilitation protocol with ceramic veneers, above all, it is characterized as
an extremely conservative condition, because it provides less preparation of the naturally
darkened teeth for shade matching, generally of a higher value than that of the ceramics
installed in addition to maintaining a greater volume of enamel.
Although all bleaching techniques available today are effective, a successful tre-
atment is directly related to the etiological factor responsible for the discoloration.4,20,45
Naturally discolored teeth or those darkened by ageing respond satisfactorily and usually
better to bleaching than those stained by intrinsic pigmentation, as caused by tetracycline
and tooth fluorosis.4,25,27,29,41 In these cases, sometimes bleaching is merely not sufficient,
and more invasive procedures may be necessary to restore the dental aesthetics through
restorative procedures.
Tooth bleaching involves the application of a carbamide peroxide (CP) or hydrogen
peroxide (HP) based agent on the tooth structure. The dynamics of the bleaching process
may be explained by the permeability of the dental structure to low molecular weight oxida-
tive free radicals, from the degradation of these peroxides and their redox chemical natu-
re.3,22,24 Thus, macromolecules of existing organic pigments in dentin are broken down into
smaller molecules, which changes their configurations and hence their optical properties,
resulting in lighter teeth.22,24
For bleaching vital teeth, bleaching agents of different concentrations may be indi-
cated for supervised at-home use, in-office application or even through the association of
both bleaching techniques. Given the various options, the dentist have questions when
choosing the bleaching gel (substance and concentration) and the bleaching technique
which will best meet each case. Therefore, the purpose of this chapter is to provide scien-
tifically-based information on the behavior of different bleaching agents and techniques
available, and so help the professional to make the right choice for the different situations
of everyday dental practice.
180
Agents used in the different bleaching techniques are basically composed of carbamide
BLEACHING AGENTS
peroxide or hydrogen peroxide.7,5 Although the chemical reactions of these bleaching agents
look similar, they are not. Therefore, different behaviors of the tooth structure about color
change, surface changes as well as tooth sensitivity may be expected when these bleaching
products are used.7 Hence the importance of knowing the specifics of the chemical reaction
of each bleaching agent, as well as to understand the reaction of the dental structures when
they are used are necessary, in order to establish an effective bleaching protocol with minimal
side effects.
Carbamide peroxide upon contact with saliva and dental tissues, dissociates into urea
and hydrogen peroxide, which, in turn, degrades into water and oxygen, which is the active
agent responsible for the oxidation reactions involved in the bleaching process.15 When using
a 10% carbamide peroxide based gel, only 3.6% hydrogen peroxide is available. It should be
noted that even when carbamide peroxide based bleaching agents of a higher concentration,
e.g. 37%, are used, the share of hydrogen peroxide is still low, around 13%.4 In addition to
allowing to provide hydrogen peroxide in low concentrations, the mechanism of action of the
carbamide peroxide neutralizes the pH of the oral environment and releases oxygen slowly.4
As the resulting hydrogen peroxide of reaction is caustic, the neutralization of the pH is of
extreme importance, since it reduces possible changes to the tooth surface.
Moreover, hydrogen peroxide is more unstable than carbamide peroxide, having a
lower molecular weight, and breaks down more rapidly into water and oxygen,15 therefore
requires less time to produce the desired action.19 Nevertheless, the need for a pH below
4.5 to maintain the stability and the absence of urea byproducts to neutralize the pH pro-
duce microscopic changes when applied on the tooth surface.14,24,25 Although microscopic
changes to the tooth surface seem negligible at first, if we consider the increase in life ex-
pectancy to approximately 80 years, this seemingly unapparent microscopic wear, started
at an early age, can become significant when elderly. In addition, greater diffusion of active
oxygen via dentinal tubules, which may reach the pulp tissue is reported in histological stu-
dies. Therefore, when higher hydrogen peroxide concentrations are used, pulpal damage
of greater intensity is reported.7,21 Considering that the concentration of the active subs-
tance of the bleaching agent is directly related to the intensity of the adverse effects,26 it is
of paramount importance to be aware of the concentration of hydrogen peroxide of each
commercially available bleaching agent (Quadro 1).
Quadro 1. Relationship of the hydrogen peroxide percentage in bleaching agents for home and in-office use.
BLEACHING AGENT PERCENTAGE OF HIDROGEN PEROXIDE
10% Carbamide peroxide 3.6%
20% Hydrogen peroxide 20%
181
In order for bleaching to occur, a minimum amount of bleaching agent must be active
DENTAL BLEACHING TECHNQUES

and available.31 Initially, satisfactory bleaching have been obtained using daily applications
of 10% carbamide peroxide with the aid of a tray for a period of 8 h,18 though laboratory
and clinical researches have shown that both the hydrogen peroxide as carbamide pero-
xide degrade rapidly in the first few hours of use: at 1 hour, the degradation of hydrogen
peroxide is approximately 68%;1 and that of carbamide peroxide is higher than 50% in 2
hours.31,32 This finding demonstrates that existing bleaching agents may be used daily for a
short period, regardless of the bleaching technique used. Thus, satisfactory bleaching has
been achieved utilizing a short time interval: half an hour to 2-hour daily application. Clinical
studies evaluating periods of less than two hours of daily use have reported color change
similar to that obtained with the same bleaching products for 8 hours.8,30 Hence the safe
modification in the at-home supervised bleaching protocol for using the bleaching for less
than 2 hours daily. Cardoso & cols,8 even showed that daily use for only 15 minutes makes
it possible to obtain satisfactory results. The decrease in contact time of the gel to the too-
th surface also helped to further reduce the already low tooth sensitivity rates reported for
at-home bleaching, especially when carbamide peroxide concentrations higher than 10%
are used. Effective bleaching without adverse effects have become increasingly present.5
As it happens slowly and gradually, color change of the teeth may be tracked individually.
Although time to obtain the desired bleaching is variable, an average of 2 to 6 weeks are
required to complete the treatment.6,28 It should be noted that the initial color is crucial in
defining this time. Therefore, bleaching A3 or darker teeth takes longer than bleaching A2
or lighter teeth.
In order to obtain satisfactory results more rapidly, bleaching products with agents of
a higher concentration have been developed. For supervised home bleaching, bleaching
based on carbamide peroxide concentrations between 10% and 22% are frequently used
by professionals. Although it seems logical that higher concentrations promote satisfactory
results in less time, clinical studies evaluating the bleaching A3 or darker teeth reported
similar treatment duration, between 4-6 weeks to achieve patients satisfaction, regardless
of the concentration (10% CP, 16% CP and 22% CP) of the bleaching agent used in the
home technique.6,34 What actually happens is a more rapid visualization of the discolora-
tion by the patient, in the first week, when bleaching agents of higher concentration are
used. However, after the third week there is no difference in color obtained through the
use of different concentrations.6 Therefore, the final treatment time will not necessarily be
shorter when higher concentration of bleaching are used. Additionally, the fact that Matis
& cols32 demonstrated that the lower the concentration of the bleaching agent used, the
most stable are the results, that is, bleaching products of a lower concentration, in addition
to being as effective as those of a higher concentration, make possible the results to be
more stable over the years.
When the search was for faster results, the in-office bleaching technique was re-
commended. However, clinical and scientific evidence shows that there is no difference
in the time of treatment required to achieve patients satisfaction when this technique is
compared to that of the at-home bleaching technique.6 Initially, the use of 35% hydrogen
peroxide-based bleaching agents for in-office application was intended to promote satis-
182
factory bleaching in a single session. With this technique, after the retraction of soft tissue
and carrying out a gingival barrier, the bleaching agent is applied on the labial surface of
the teeth and maintained for approximately 45 minutes.5,33 When removing the product,
color change is generally already noticeable by the patient. In such cases, bright teeth re-
sult from the action of the bleaching agent and tooth dehydration resulting from the relative
isolation required to perform the technique. Thus, after dental rehydration, which can take
up to 3 days, color reversal occurs and teeth appear less clear.4 In fact, the color after
rehydration is actually reached in the bleaching session, which normally does not meet
patient’s expectations, making it necessary for more bleaching sessions. To bleach teeth
with initial color A3 or darker six sessions or more may be required to achieve patient’s
satisfaction, depending on the case and the bleaching agent used.6,17 Weekly applications
of the product are recommended due to the high concentration of hydrogen peroxide,33
requiring 6 weeks for patient’s satisfaction. Furthermore, the high concentration of hydro-
gen peroxide may cause high intensity tooth sensitivity, due to the diffusion of the product
via dentinal tubules, reaching the pulp tissue.10,11,17,23,33 In such cases, analgesics may be
required to facilitate the treatment. Even though there is not any longitudinal clinical resear-
ch with a representative sample evaluating the pulp response to in-office bleaching, in situ
studies have reported pulp necrosis in mandibular incisors when 38% HP was used.11 In
addition to reversible (high intensity tooth sensitivity)23,33,38,42 or irreversible (pulp necrosis)11
pulp damage, clinical studies have reported that the low stability of bleaching obtained by
the in-office technique with 35% to 38% hydrogen peroxide; after 6 months of treatment
one may already perceive color reversal.17,36
A 37% carbamide peroxide-based bleaching agent has been commercially available
for in-office use. When in contact with the tooth structure, 37% carbamide peroxide disso-
ciates by approximately 13.3% hydrogen peroxide and 10% urea. The lowest concentra-
tion of HP in the product enables in-office daily applications of up to 45 minutes with a low
risk of tooth sensitivity.16 Clinical studies have showed that applications for 6 consecutive
days provided color change similar to that obtained with four weekly sessions of 38% HP.9
Another important factor is that these six applications may be carried out all on the same
day. Besides satisfactory bleaching in just 1 day, or in 1 week (cases of applications in se-
quential days) of treatment, a clinical trial found that only 20% of the patients experienced
mild tooth sensitivity, beginning after the fourth day of the consecutive application of the
product.9 Although the product can be safely applied in daily sessions, the patient’s low
tolerance threshold of pain of the may require alternate days of applications, which elimina-
tes any painful symptomatology. Another advantage of using the 37% CP is the possibility
of simplifying the application technique, being that the gingival barrier is not necessary,
although the clinician may if deemed necessary. Thus, after the removal of soft tissue the
product that requires no mixing is applied on the labial surface of the teeth.
Although in-office bleaching has such advantages, as the rapid visualization of color
change, the availability of time for the various in-office sessions for the patient may be con-
sidered disadvantageous, in addition to making the procedure most expensive. In order to
make the procedure feasible for all patients, an alternative that has been well accepted by
professionals is associating the bleaching techniques, combining the best characteristics of
183
in-office bleaching with the at-home bleaching.4,13 In-office sessions, using 37% CP or 38%
HP for 45 minutes, are used concomitantly wih daily applications of 10% or 16% CP. Initially,
an in-office session is performed with the goal of producing a noticeable color change after
removal of the product. Then the color change continues to occur gradually through daily
applications by the at-home technique and a second In-office session may then be carried
out, in order to enhance the speed of the bleaching therapy. Daily applications for at-home
use are maintained until the end of the treatment. Some of the advantages of associating
bleaching techniques which may be cited are: satisfactory results in the shortest time; re-
ducing the inherent sensitivity to the in-office bleaching; reducing the treatment costs, being
that fewer in-office sessions will be necessary; and greater longevity of the bleaching will be
achieved.13
Establishing a single protocol for the bleaching treatment is totally impractical, given
TREATMENT
PROTOCOL
the different responses of bleaching agents when applied to the tooth structure. Despite
being simple, there is a universal pursuit for having white teeth without any pain symptoms.
Even though product characteristics may be influenced with the appearance of tooth sen-
sitivity, from inherent characteristics of the patient, due to ones threshold of pain tolerance,
psychological aspects, areas of dentin exposure and sensitivity prior to the beginning of
treatment, are determining factors which can explain the appearance of the painful symp-
toms even when placebo gels are used in clinical research.12,21,40 Hence the need to carry
out an accurate diagnosis, since the presence of tooth sensitivity can delay the start of
treatment. In these cases, topical application of fluoride, fluoride mouthwash or treatment
with the potassium nitrate and potassium oxalate based desensitizers are recommended
prior to the start of the bleaching and, if possible, should be maintained throughout the
tooth bleaching process.12
Even if desensitizing agents are present in all bleaching products currently availa-
ble, the concentration of the product and the time it remains in contact with the tooth
37
structure may result in different pulp responses.21 Therefore, some strategies can be used
to reduce tooth sensitivity rates prior, whether they are existent or not:
184
1. in cases of previous sensitivity, perform treatment with desensitizers (potassium oxa-
late, strontium chloride, potassium nitrate or fluorides) before whitening;
2. seal, initially, areas of exposed dentin with glass ionomer cement and/or composite
resin;
3. seal cracks, when present, with a bonding agent or composite restorations;
4. select bleaching gels that have low tooth sensitivity rates, proven by clinical research;
5. pay attention to the fact that patients with a history of sensitivity should take special
care – lower concentration bleaching agents and lower daily application regimens
should be recommended; for example, 10% carbamide peroxide for 15 minutes;
6. choose carbamide peroxide based bleaching gels, both for at-home as well as for
in-office application techniques;
7. reduce the time of application of bleaching agent; for example, apply for 20 minutes
in the in-office session and/or reduce for 15-30 minutes of daily use in the tray;
8. apply bleaching on alternating days, both for the at-home and in the in-office tech-
nique sessions; and
9. associate tooth bleaching techniques, in-office and at-home.
It should be emphasized that although reducing the contact time of the gel on the tooth
structure and the reduction of the concentration of the product prolong the time to complete
the bleaching treatment, this strategy will enable the bleaching of more sensitive teeth.8
Several professionals report that patients who have bleached their teeth frequently com-
plain about the appearance of cracks and stains. Literature on the subject shows that there
are not any available agent or technique which would produce spots and/or cracks, which
leads us to conclude that they already existed and only became visible.4 For this reason, we
consider it essential to transilluminate the teeth before initiating the bleaching treatment and
show the patient the possible existence of cracks and stains, as well as to advise them as to
whether they become visible after bleaching.
Another difficulty encountered in the protocol is to establish a minimum period for the
bleaching treatment, considering the different color tones that natural teeth present and the
different degrees of bleaching desired by each patient. Thus, the dentist should be able to
tell the difference between a result they consider satisfactory and the result desired by the
patient. This may involve the reduction of several days of treatment, even for patients with
more yellowish teeth, or performing only one in-office session to meet patients who already
have white teeth or that do not wish teeth so clear.Therefore, establishing a single treatment
period, e.g., 30 days, may represent overtreatment for some patients, while a period of 15
days may be insufficient for other. Concerning the different color tones in the dental arch, it is
noteworthy that darker teeth will require stronger action of the bleaching agent in contact with
the tooth structure to equalize the shade with the brightest teeth of the arch. This may imply
only bleaching the saturated teeth for a greater number of days or the association of in-office
applications solely for these teeth in order to accelerate the bleaching treatment.
185
Another question of professionals is when to stop bleaching, especially when seeking
very white teeth. Even though the literature considers the saturation point – when there is no
dye molecules to be broken and the bleaching gel starts to degrade the organic matrix of den-
tin – as the limit for brightening the tooth structure clinically is impossible to be established.39
Thus, we believe that the limit for bleaching naturally discolored teeth or those darkened by
age should be determined from the stabilization of the color of the tooth structure in the weekly
return appointments for evaluation of bleaching, while the patient is still not satisfied with the
result.
As seen, any product which carbamide peroxide or hydrogen in its composition will
promote bleaching of the tooth structure. Thus, the use of mouthrinses and toothpastes in-
tended to be “bleaching” may be used as an aid in maintaining the achieved bleaching for
at-home and/or in-office techniques. On its own, this type of product, if used for years, will
also promote discoloration of the tooth structure,44 in the same way the use of whitening strips
sold in drugstores and grocery stores are effective. However, any option, if unattended by
the professional, will cause aesthetic damages, sometimes irreversible. Therefore, the best
technique will be that which is surely indicated by the professional and that which meets the
needs of the patient.
Finally, another frequent question is concerning how long to wait before accomplishing
the restorative procedures. As seen during the bleaching technique tooth dehydration in dif-
ferent intensities takes place, responsible for making teeth lighter than they actually are. The-
refore, we recommend to wait the minimum length of seven days after finishing the bleaching
treatment to accomplish the restorations, whether direct or indirect.35,43 In addition to tooth
rehydration and stabilization of the color obtained, according to the literature this period is su-
fficient for any remaining oxygen is eliminated from the tooth structure,35 causing the adhesive
bond strength values of the direct and indirect restorations not to be compromised, which will
prolong the longevity of the restorative treatment.
With the different bleaching techniques and the wide variety of commercially available
products, it is possible to promote tooth bleaching with a minimal of side effects with different
intervals of treatment, and it is even possible to bleach overly sensitive teeth. Unquestionably,
our recommendation is using carbamide peroxide based products, since all clinical studies
show them to be safer for bleaching. However, it is essential to know the mechanism of action
of products available and how they should best be managed to achieve the desired results in
different clinical situations.
The case presented in the photographs (Fig. 1-8) illustrates the clinical management
performed in the care of a patient who aimed to bleach teeth and close the interdental spaces
with ceramic veneers.
186
Figure 1a-d.Facial photographs with the initial appearance of a 25 year-old male patient, who sought care aiming to to have white teeth without interdental spaces..
Photographs taken by Dudu Medeiros.
187
Figures 2a-c. The photos of fa orced smile is observed in addition to the disharmony of the color of teeth involved in the aesthetics of the smile, a significant discrepancy in the length of canine teeth due to
gingival recession.
Figures 3a-b. Intraoral photographs taken 180 days postoperative follow-up in the region of 13 submitted to the subepithelial connective tissue graft technique for correction of gingival recession, and
clinical crown lenghtening on teeth 11 and 12, which greatly compromised the smile aesthetics (see Chapter 5.2).
Figures 4a-b. As indirect veneers would be carried out to restore the dental proportions closing the existing diastemata and the color of the indirect restorations would be determined considering the color
of the natural teeth, they would not be involved in the restorative treatment, it was essential to initiate the tooth bleaching treatment. As posterior teeth were darker than the anteriors and the patient did
not exhibit sensitive teeth, it was decided to associate both the home and the in-office bleaching techniques in order to reduce the treatment time. With the help of the shade guide (Vita Classical®, Vita,
Germany) it was possible to observe the degree of tooth darkening, highlighting the most saturated color of the posterior teeth. These photographs were also required to record the initial color of the teeth
before initiating the bleaching treatment, for use for future reviews.
Figures 5a-b. Bleaching was carried out for 16 days by the at-home technique, using a 16% carbamide peroxide product (BM4, Florianópolis, Brazil) for 2 hours daily, associated with three daily
applications of in-office 37% carbamide peroxide (BM4, Florianópolis, Brazil)for 45 minutes, on all of the teeth. After 4 days of the last clinical session, it was observed that only the posteriors were
unsatisfactory color. Three additional daily clinical applications were repeated, from the canines to the posteriors, concurrently with the daily use of 16% carbamide peroxide to enhance the results. After
10 days of treatment with the aid of the shade guide (Vita Classical®, Vita, Germany), the color change achieved with the combined bleaching techniques may be observed.
188
Figure 6d.
Figure 6e.
Figure 6f. Figure 7.
Figures 6a-f. Satisfactory result desired by the patient, after 10 days of tooth bleaching. No symptoms of sensitivity were reported during treatment. As completion of treatment would be with indirect
veneers, seven days were expected for tooth rehydration and stabilization of the final color obtained. After this period, the remaining oxygen in the tooth structure would have been released and restorative
procedures could be accomplished without compromising the strength values of the adhesive bond. Final laboratory aspect of the ceramic restorations (a) and after cementation of the veneers (12-22)
and fragments (13 and 23), made from feldspathic ceramic (b). In the interocclusal photo (c) it is observed that the new dental proportions are properly adjusted to the patient’s occlusion. In the smile (d)
the harmony achieved from the correction of the gingival zenith and new proportions (length and width) of the anterior teeth can be observed. Finally, pictures with the shade guide (Vita Classical®, Vita,
Germany) demonstrate the success of the association of the ceramic veneers and bleaching techniques, having obtained an aesthetic resulting from a conservative approach, due to the elimination of the
need to carry out tooth preparation to offer greater volume for the application of the ceramic and masking the color of the substrate (e-f).
Figures 7 and 8. Harmony in the rehabilitation assembly with ceramic veneers and the result optimized by the the bleaching technique carried out. Photographs taken by Dudu Medeiros.
189
Figure 8.
190
191
1. Al-Qunaian TA, Matis BA, Cochran MA. In vivo kinetics of bleaching gel with three-percent hydrogen peroxide within the first
REFERENCES
hour. Oper Dent. 2003;28(3):236-41.
2. Azer SS, Rosenstiel SF, Seghi RR, Johnston WM. Effect of substrate shades on the color of ceramic laminate veneers. J
Prosthet Dent. 2011;106(3):179-83.
3. Baratieri LN, et al. Clareamento de dentes. In: Baratieri LN. Odontologia restauradora: fundamentos e possibilidades. São
Paulo: Santos; 2001. p. 675-722.
4. Baratieri LN, Maia E, De Andrada MAC, Araújo E. Caderno de dentística: clareamento dental. São Paulo: Santos; 2003
5. Bernardon JK, Baratieri LN. Clareamento de dentes vitais. In: Barateiri et al. Soluções clínicas: fundamentos e técnicas.
Florinópolis: Ponto; 2010. p. 89-107.
6. Bernardon JK, Ferrari P, Vieira LCC, Maia HP. Avaliação do tempo de tratamento para a satisfação do paciente nas diferentes
técnicas de clareamento. In: 27ª Reunião Anual da SBPqO, 2010, Águas de Lindóia - SP. Brazilian Oral Research; 2010.
p. 271.
7. Bernardon JK, Sartori N, Ballarin A, Perdigão J, Barateri LN. Clinical performance of vital bleaching techniques. Oper Dent.
2010;35:3-10.
8. Cardoso PC, Reis A, Loguercio A, Vieira LC, Baratieri LN. Clinical effectiveness and tooth sensitivity associated with different
bleaching times for a 10 percent carbamide peroxide gel. J Am Dent Assoc. 2010;141(10):1213-20.
9. Carvalho LD, Brusi G, Bernardon JK, Baratieri LN. Cabamide peroxide vs hidrogen peroxide in-office bleaching: efficacy,
treatment time and post-operative sensitivity. Oper Dent. 2014, no prelo.
10. Costa CAS, Huck C. Cytotoxic effects and biocompatibility of bleaching agents used in dentistry: a literature review. Robrac.
2006;15(39):3-14.
11. Costa CAS, Riel H, Kina JF, Sacono NT, Hebling J. Human pulp responses to in-office tooth bleaching. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 2010;109(4): 59-64.
12. Cunha-Cruz J, Stout JR, Heaton LJ, Wataha JC. Dentin hypersensitivity and oxalates: a systematic review. J Dent Res.
2011;90(3):304-10.
13. Deliperi S, Bardwell DN, Papathanasiou A. Clinical evaluation of a combined in-office and take-home bleaching system. J
Am Dent Assoc. 2004;135(5):628-34.
14. Elfallah HM, Swain MV. A review of the effect of vital teeth bleaching on the mechanical properties of tooth enamel. N Z Dent
J. 2013;109(3):87-96.
15. Fasanaro TS. Bleaching teeth: history, chemicals, and methods used for common tooth discolorations. J Esthet Dent.
1992;4(3):71-8.
16. Gallo JR, Burgess JO, Ripps AH, Bell MJ, Mercante DE, Davidson JM. Evaluation of 30% carbamide peroxide at-home
bleaching gels with and without potassium nitrate: a pilot study. Quintessence Int. 2009;40(4):1-6.
17. Gottardi SM, Brackett MG, Haywood VB. Number of in-office lightactivated bleaching treatments needed to achieve patient
satisfaction. Quintessence Int. 2006;37(2):115-24.
18. Hatwwod, VB, Heymann HO. Nightguard vital bleaching. Quintessence Int. 1989;20(3):173-6.
19. Haywood VB, Leonard RH, Nelson CF, Brunson WD. Effectiveness, side effects and long-term status of nightguard vital
bleaching. J Am Dent Assoc.1994;125(9):1219-26.
20. Joiner A. The bleaching of teeth: a review of the literature. J Dent. 2006; 34:412-9.
21. Jorgensen, MG, Carroll WB. Incidence of tooth sensitivity after home whitening treatment. J Am Dent Assoc. 2002;23:1076-
82.
22. Kawamoto K, Tsujimoto Y. Effect of the hydroxyl radical and hydrogen peroxide on tooth bleaching. J Endod. 2004;30(1):45-
50.
23. Kina JF, Huck C, Riehl H, Martinez TC, Sacono NT, Ribeiro APD, Costa CAS. Response of human pulps after professionally
applied vital tooth bleaching. Int Endod J. 2010;43;572-80.
24. Kwon SR. Whitening the single discolored tooth. Dent Clin North Am. 2011;55(2):229-39.
25. Kwon SR, Wang J, Oyoyo U, Li Y. Evaluation of bleaching efficacy and erosion potential of four different over-the-counter
bleaching products. Am J Dent. 2013;26(6):356-60.
26. La Penã AV, Cabrita B. Comparison of the clinical efficacy and safety of carbamide peroxide and hydrogen peroxide in at-ho-
me bleaching gels. Quintessence Int. 2006;37(7):551-6.
27. Leonard RH Jr, Haywood VB, Eagle JC, Garland GE, Caplan DJ, Matthews KP, et al. Nightguard vital bleaching of tetracy-
cline-stained teeth: 54 months post treatment. J Esthet Dent. 1999;11(5):265-77.
28. Leonard Jr H, Bentley C, Eagle JC, Garland GE, Knight MC, Phillips C. Nightguard vital bleaching: a long-term study on
efficacy, shade retention, side effects, and patients’ perceptions. J Esthet Restor Dent. 2001;13(6):357-69.
29. Leonard RH Jr, Haywood VB, Caplan DJ, Tart ND. Nightguard vital bleaching of tetracycline-stained teeth: 90 months post
treatment. J Esthet Restor Dent. 2003;15(3):142-52.
30. Marson FC, Sensi LG, Araujo FO, Monteiro-Junior S, Araújo E. Avaliação clínica do clareamento dental pela técnica caseira.
Rev Dental Press de Est. 2005;2(4):84-90.
31. Matis BA, Gaiao U, Blackman D, Schultz FA, Eckert GJ. In vivo degradation of bleaching gel used in whitening teeth. JADA.
1999;130(2):227-35.
32. Matis BA, Yousef M, Cochran MA, Eckert GJ. Degradations of nine bleaching gels after two hours in vivo. Oper Dent.
2002;27(1):12-8.
33. Matis BA, Cochran MA, Franco M, Al-Ammar W, Eckert GJ, Stropes M. Eight in-office tooth whitening systems evaluated in
vivo: a pilot study. Oper Dent. 2007;32(4):322-7.
34. Meireles SS, Heckmann SS, Leida FL, dos Santos Ida S, Della Bona A, Demarco FF. Efficacy and safety of 10% and 16%
carbamide peroxide tooth-whitening gels: a randomized clinical trial. Oper Dent. 2008;33(6):606-12.
35. Miranda TA, Moura SK, Amorim VH, Terada RS, Pascotto RC. Influence of exposure time to saliva and antioxidant treatment
on bond strength to enamel after tooth bleaching: an in situ study. J Appl Oral Sci. 2013;21(6):567-74.
192
36. Moghadam FV, Majidinia S, Chasteen J, Ghavamnasiri M. The degree of color change, rebound effect and sensitivity of blea-
ched teeth associated with at-home and power bleaching techniques: a randomized clinical trial. Eur J Dent. 2013;7(4):405-
11.
37. Navarra CO, Reda B, Diolosà M, Casula I, Di Lenarda R, Breschi L, Cadenaro M. The effects of two 10% carbamide peroxide
nightguard bleaching agents, with and without desensitizer, on enamel and sensitivity: an in vivo study. Int J Dental Hygiene.
2014;12(2):115-20.
38. Pugh G Jr, Zaidel L, Lin N, Stranick M, Bagley D. High levels of hydrogen peroxide in overnight tooth-whitening formulas:
effects on enamel and pulp. J Esthet Restor Dent. 2005;17(1):40-5.
39. Riehl H, et al. Clareamento de dentes vitais e não vitais: uma visão crítica. In: Fonseca AS. Odontologia estética: a arte da
perfeição. São Paulo: Artes Médicas; 2008. p. 499-565.
40. Rosenthal MW. Historic review of the management of tooth hypersensitivity. Dent. Clin N Amer. 1990;34:403-27.
41. Sundfeld RH, Sundfeld-Neto D, Machado LS, Franco LM, Fagundes TC, Briso AL. Microabrasion in tooth enamel discolora-
tion defects: three cases with long-term follow-ups. J Appl Oral Sci. 2014;22(4):347-54.
42. Trindade FZ, Ribeiro AP, Sacono NT, Oliveira CF, Lessa FC, Hebling J, et al. Trans-enamel and trans-dentinal cytotoxic effects
of a 35% H2O2 bleaching gel on cultured odontoblast cell lines after consecutive applications. Int Endod. 2009;42(6):516-
24.
43. Torneck CD, Titley KC, Smith DC, Adibfar A. The influence of time of hydrogen peroxide exposure on the adhesion of com-
posite resin to bleached bovine enamel. J Endod. 1990;16(3):123-8.
44. Torres CR, Perote LC, Gutierrez NC, Pucci CR, Borges AB. Efficacy of mouth rinses and toothpaste on tooth whitening. Oper
Dent. 2013;38(1):57-62.
45. Watts A, Addy M. Tooth discoloration and staining: a review of the literature. J Br Dent. 2001;6:309-16.
193
chapter 5.4
occlusal plastic restorative therapy
João Christovão Palmieri Filho
How to justify the vast number of relatively young patients seeking treatment for
extensive dental destruction? (Fig. 1, 2 and 3) Not infrequently the main complaint of
this group of individuals is concerning the poor appearance brought by that destruction.
For a while, Dentistry came to believe that the strict oral microbiological control would be
enough to prevent this from happening. However, these patients even in the face of low
rates of decay or with few restored teeth, have wear or loss of coronary portions that justify
the dental rehabilitation. In this way, professionals are facing an era when biomechanical,
behavioral and environmental factors start to play an important role in the genesis of what
has been called the occlusal disease.1
The occlusal disease was defined as the loss of anatomical portions of the teeth par-
ticipating in the occlusion. Better explained, it is the loss of the original anatomical contour
due to friction between the teeth, with or without interposition of abrasive agents or aci-
dic substances. In this context, bruxism appeared as an event-disease and main causal
agent of this type of wear, ie, the association between bruxism and occlusal disease has
become practically unequivocal.
However, there is evidence that bruxism is associated with stress relief.2 In this case,
bruxism cannot be considered a disease; on the contrary, it should be considered a pro-
tective factor. This becomes clearer when it was observed that the genesis of this intense
masticatory activity is located in the central nervous system (CNS).9 The teeth are at the
end, not at the beginning of this chain of events. One would then question: the muscles
that move the jaw and which generates work between teeth obeys a command center
regardless of the stimuli that these teeth send to the CNS? The answer is not yet clear, but
it is known that teeth are organs of physical and immunological modulation of a particular
lifestyle. The lifestyle of the “modern human”.
Therefore, the loss of part of alveolar bone structure due to biomechanical fatigue
becomes associated with a factor outside the occlusal system. And Dentistry, out of its
own desperation, has become responsible for a risk factor which is independent of teeth.
To make an analogy, the quality of a vehicle is independent of the driver’s intentions.
An unbalanced car in the hands of a calm and careful driver is less prone to accidents than
a powerful and balanced car in the hands of a reckless, inconsequent driver. The driver,
in this case, is the CNS.
For the professionals who dedicate their lives to the rehabilitative dentistry, the pos-
sibilities of rebuilding and adjusting these occlusal systems remain in the most balanced
manner as possible, from anatomical, neuromuscular and social point of view. And hope
the “driver” to be prudent and observant.
196
Figure 2. Figure 3.
Figure 4.
Figures 1-4. Frontal in maximal intercuspation and upper and lower occlusal photographs of a 28 year old patient presenting initial degree of coronary destruction attributed to parafunctional habits such
as nocturnal bruxism. Severe cusp abrasion is observed. From canine to third molars, geometrically sharp portions of wear can be identified.These paths may be termed cuspal or crestal remaining
bases. This concept will be of great value in the reconstruction of the original anatomical shape.
197
The evolution of materials and techniques in Dentistry have made possible the reha-
SOCIAL
FUNCTIONS
OF TEETH
bilitation of the dental occlusion without necessarily having to reduce and destroy the tooth
remnants. The possibility of veneering the crown of a tooth with pure fused or machined
porcelain, bonded to the coronal structure by a thin layer of resin cement, has made this
prosthetic assembly as much or more resistant than the original tooth,3 which has become
the cornerstone of current dental rehabilitation.
At this turning point from the old mechanical retention standards to the undeniable
method of adhesive retention, this chapter addresses the principles, concepts and prac-
tices of the classical occlusal rehabilitation which should remain and what is more prevail
in this new era, predicted more than 50 years ago by Buonocore.4
If the basis of our current technology was born out of the work of the professionals
for over five decades, one should bring to memory those works which have allowed us to
get here. The idea of terminal axis established by final position of the heads of the man-
dible against the mandibular fossa with increased power of the lifting muscles (masseter,
temporal and internal pterygoid) working free from dental contacts, is not new5 and it is
fundamental to Dentistry to be applied, as well as the demonstration of the role played by
the tooth contact (and by the absence of this contact as well) on this very musculature.6
Upon this basis, of a hundred of years, has described and demonstrated a means of
restoring the occlusal balance, indispensably necessary for the durability of rehabilitations
and the comfort of the patients as well.
In epidemiological terms, the aim of every rehabilitation is limiting the damage and
OCCLUSAL
REHABILITATION AS
TERTIARY PREVENTION
recovering of the residual capacities. Its ideal is returning to the individual primary and
secondary levels of prevention.7 Referring to the occlusal rehabilitation, one must keep
in mind the recovery of the bite force, the masticatory ability, good appearance and the
consequent social impact this represents. The rehabilitation of the patient’s occlusion is
closely related to the overall health of the individual.8 Figure 1 helps to situate the concept
of rehabilitation as a tertiary prevention.
The dental practice, as a health science, can be readily framed into different levels
of attention. For example, the instruction of oral hygiene to patients fits into the first level of
the scale, primary prevention, as a health promotion measure. Still at the level of primary
prevention, topical application of fluoride or even carrying out pit and fissure sealants are
specific measures of protection. From the third to the fifth levesl, the focus is on working
with the rehabilitation of health. From the point of view of occlusion, when the professional
deals with an initial carious lesion, early diagnosis and proper treatment are performed.
Accomplishing an endodontic treatment on this very tooth limits the damage and allows for
the element to be restored to the occlusal function. When the entire set of teeth inexorably
moves toward a collapse, the fifth level is reached: the occlusal rehabilitation.
198
Quadro 1. Application levels of health measures and equivalence of terms used for designation. From Pereira, Maurício: Epidemiology Theory and Practice. Guanabara Koogan, 1995.
FIRST LEVEL SECOND LEVEL THIRD LEVEL FOURTH LEVEL FIFTH LEVEL
Health promotion Specific protection Early diagnosis and timely Limitation of the damage Rehabilitation
. . treatment . .
Prevention Prevention Care Care Rehabilitation
Primary prevention Primary prevention Secondary prevention Secondary prevention Secondary prevention
Promotion Protection Recovery Recovery Recovery
Instruction oral hygiene/ Topical application of Restoration/orthodontics/ Endodontics, implant, crowns, Tooth- and/or implant- or
nutritional counseling fluoride / sealants orthognatics extensive restorations etc. tissue-supported prostheses
It is pertinent to note that, as the treatment progresses along this scale of prevention,
the level of expenditure rises. The amount to be spent on an occlusal rehabilitation may
be hundreds of times higher than that of the value of a dental prophylaxis. Even within the
therapeutic possibilities of Dentistry, an occlusal rehabilitation using composite resin or
ceramic veneers tend to be more economical than the equivalent job that uses osseoin-
tegrated implants and porcelain crowns. And not only from a financial perspective, but
especially from a biological sense.
Each and every treatment should be preceded by the proper diagnosis. This clinical
THE STARTING POINT
FOR AN OCCLUSAL
REHABILITATION
truth is often set aside when it comes to rehabilitation of the occlusion. Treating a diseased
occlusion without identifying, qualifying and quantifying the disease is akin to merely per-
forming palliative procedures and running the risk of making temporary crowns as definitive
restorations.
The diagnosis of the occlusal disease indicates that it should analyze the amount
and frequency of parafunction or hyperfunction performed by the patient. The higher the
degree of occlusal imbalance and the greater the level of parafunction, the greater the
destruction of the tooth.1
The occlusal diagnosis can not be performed through the mere observation of the
coronary destruction. The alveolar bone, periodontal ligament, joints, muscles, and espe-
cially the neuromuscular coordination should receive attention during the formulation of
the hypotheses about how, when and why a system that should function without damage
could progress towards its collapse.
199
As stated earlier in this chapter, dental destruction by biomechanical factors, of-
IDENTIFYING THE
OCCLUSAL DISEASE
BY THE SMILE
ten, seems to overcome destruction generated by microbiological factors. Considering
that this type of destruction takes place over several years and requires time to become
evident, the early diagnosis allows for a less invasive intervention and more predictable
results, equally in terms of aesthetics as well as the longevity of the treatment.
In Figure 4, from the picture of the smile it is possible to infer the following conside-
rations:
1. reduction of incisal edges and cusp tips took place, principally of the canine teeth;
and
2. there is a swelling on the left side of the lower lip, which could have been caused by
recurrent unconscious trauma (morsicatio labiorum).
Starting from these two considerations, it is interesting to ask the individual about
habits and manias. Normally, the answer obtained that both the grinding of teeth such
as repetitive lip biting, if it really occurs, happen overnight or unconsciously. Also not in-
frequently, in subsequent appointments, the patient reports situations where a repetitive
habit has been properly noticed (Fig. 5). Eventually, there may be a report by the family
or friends concerning sounds of tooth grinding during sleep. If this is enough to confirm a
classic case of sleep bruxism,9 it is up to the professional to explain what the relationship
is between bruxism and stress relief.2
Figure 5. Figure 6.
Figure 5. Questioned and instigated to produce a repetitive and unconscious habit, the individual is able to reveal to the professional, and often himself, situations comparable to self-flagellation.
Figure 6. When evaluating the degree of coronary destruction one should consider the age of the individual. In the case described in this chapter, the patient is young (28 years), so the loss of the cusp
tips of the canine and incisal edges and “peeling” of the resin in the cervical region of the first premolar indicates severe attrition and overloading, some abrasion by toothpaste abuse and a little erosion
of coronary surfaces.
200
Tooth wear is a process with a multifactorial cause that leads to the loss of enamel
BEYOND ATTRITION,
EROSION AND ABRASION
and dentin as well as pulp sclerosis. This loss of substance can occur by dental attrition
of a tooth against a tooth by acid erosion or abrasion by external agents, as in cases of
excessive dentifrices or abrasive food.10,11 It is noteworthy that, in practice, rarely is there
a single factor that acts in the loss of tooth substance.
Loss due to attrition can be diagnosed by the polished appearance of opposing
tooth surfaces, as well as by the perfect fit of the forms of wear between antagonist teeth.
In severe cases, there is also some masseter hypertrophy, by a noteable scalloped appe-
arance of the edges of the tongue and report of repeated mucosal lesions.
Both enamel and dentin will dissolve in an acidic environment. The origin of this aci-
difying agent can be both extrinsic (juices, soft drinks or medicines) and intrinsic (stomach
acid from reflux). In extremely low pH conditions with the oral cavity, the attrition of the
tongue becomes an adjunctive agent of erosion. Therefore, there is characteristic wear on
the palatal surfaces of the anterior and internal cusps of the posterior.
Toothpaste abuse is an abrasive factor that cannot be overlooked. It is believed
that, because it is a product for daily use, it is capable of removing tooth substance if used
in excess. And the damage may be aided by the phenomenon of abfraction.12
The importance of identifying different patterns of loss of tooth structure lies in the
accuracy of the diagnosis. For example, measures of occlusal reconstruction and the
use of bite splint may be sufficient for rehabilitative treatment, However, in the case of a
patient with a severe gastric reflux, additional control measures should be taken. At that
moment the accuracy of diagnosis will easily convince the patient to seek help from an
expert. In addition, the dentist stops being merely a mouth mechanic and behaves like a
health professional.
Initially described as a process resulting from noticeable loss of structure and des-
THE OCCLUSAL
DISEASE
truction of the coronary surfaces of the teeth, the concept of an occlusal disease has
evolved to include any change that results from overloading and imbalances in the
occlusal system.13
Thus, one must expand the analysis and move beyond the restorative view of the
tooth and periodontium. Manifestations of the occlusal disease occur throughout the
system: the temporomandibular joints (TMJ), the muscles, the degree of bone conden-
sation or rarefication and even the perception of “bite comfort” felt and reported by the
patient.
201
The occlusal system (OS) comprises the set of teeth and the periodontium, the
THE OCCLUSAL
DIAGNOSTICS
maxilla and the mandible, temporomandibular joints, the muscles involved in the mobility
of the jaw, facial movement and tongue, and, of course, the relevant neural pathways
that act, react and especially coordinate movements.
Therefore, the occlusal diagnosis will evaluate each of these components. Althou-
gh the occlusal rehabilitation basically deals with the modification and recovery of the
shape of the teeth, a proper diagnosis will allow refering patients to other specialties. It
is always a valid warning that even an ideal treatment, a misdiagnosis is a potentially a
misguided treatment.
It is possible to start with articular evaluation. This chapter does not describe the
pathophysiology of the TMJ, however starting an oral therapy regardless of the state of
this important component is a risk we should avoid. Although there is quite sophisticated
equipment for the evaluation of joint vibrations as well as advanced diagnostic imaging,14
are considered here is merely an appreciation of mobility, production of noise and the
presence of joint pain as part of the obligatory initial evaluations. It is recommended
for further study reading the book of Professor Anika Isberg Temporomandibular Joint
Dysfunction, a guide for the clinician. Despite the years since its publication, this work
seems to be very didactic and easy to assimilate by the rehabilitating clinician.
Ask the patient to open and close the mouth allowing the professional to place the
index and middle fingers to anatomically identify the heads of the mandible (condyles)
as well as to locate the right and left joints (Fig. 7a). In this region, we can palpate with
force equivalent to 1 or 2 kg searching for sensitivity. These areas are basically from the
capsule or even from the temporomandibular ligament, when palpating the lateral con-
dylar aspect towards the temporal region. With the mouth wide open, the index finger
is placed in the distal condylar pole, it is possible to palpate the retro-disc region (Fig.
7b). This maneuver should be performed with care and gentleness. Since this is a richly
innervated and vascularized region, there is risk of sharp surging pain, most importantly
not begin any palpation by applying a 2 kg force. One can start with a tenth of that. This
observation serves for the whole examination. Some patients have acute pain after a
simple light rubbing of the finger. Continuing the examination, one can explore the mas-
seter (Fig. 7c) the temporal (Fig. 7d) and the lateral pterygoid muscles (Fig. 7e).
The result of these examinations can be classified as: painless, mild, moderate or
severe pain. Remember that the pain is pathognomonic of inflammation, parameter that
can also be used during muscle palpation.
Articular changes are not rarely accompanied by muscle disorders. Therefore, it
is necessary to identify clinically the weight of each component in the generation of
dysfunction in the system. This is because it is believed that intra-articular pathologies
are not likely to heal through the occlusal rehabilitation. At best, the treatment will allow
for a functional adaptation, an inflammatory remission or stabilization of the degenera-
tive picture. On the other hand, in the predominantly muscular disorders, the balance
of occlusion will generate very positive responses in the reports of our patients. From
the electromyographic point of view, this better performance will translate into lower
electric potentials at rest and better coordination of movements.15 Electromyography is
202
not routinely indicated for diagnostics. However, it is quite enlightening to show how the
masseter and anterior bundle of temporal muscles behave, in cases of occlusal imba-
lance and how it is possible to manipulate these electric potentials by changing only and
uniquely the dental contacts.
Figure 7d.
Figure 7e. Figure 8.
Figures 7a-e. The survey of muscle palpation seeks to identify points of rigidity and pain in muscles and ligaments. It is a test that can be accomplished in less than 3 minutes and will certainly enhance
the diagnosis.
Figure 8. The patient underwent electromyography of masseter and anterior temporalis. Despite the possibility of identifying changed electrical patterns for both resting and maximum bite positions and
lateral movements, such information should be accounted for with those other collected during our occlusal examination.
203
The obtaining of study models mounted on a terminal rotation axis of the mandible
WHY TO SEARCH FOR

A TERMINAL AXIS OF
ROTATION?
(TRA), in a semiadjustable articulator, is a mandatory step for proper occlusal diagnosis.
All of the registrations - maxillary and mandibular study impressions, auricular facial bow,
resin or impression compound anterior jig, and wax or elastomer interocclusal registrations
– are procedures that with a little practice can be performed in less than 30 minutes. Se-
miadjustable (A7 Plus®, BioArt, Brazil) or mean value (A7 Fix®, BioArt, Brasil) articulators are
inexpensive and very reliabile equipment. With this information, one wonders: why too few
professionals lay hold of an occlusal diagnosis in TRA? If the time spent in obtaining the
information is less than the expenses to make a simple repair on a restoration that insists
on fracturing and the equipment used is less costly than a newly installed porcelain crown
which has already fractured, a reasonable explanation for the giving up of the occlusal
diagnosis thereby is simply not knowing how to use an articulator.
The so-called central relationship (CR) is a reference position between the mandible
and maxilla. When both heads of the jaw reach that position, they establish a virtual axis
which we call the terminal rotation axis or terminal hinge axis (TRA or THA). It is in the
condylar position of maximum intrusion when the lifting muscles are triggered without the
interference of the teeth, the individual can achieve TRA in working CR. There are some tri-
cks for recording that position. Both the bidigital manipulation technique indicated by Peter
Dawson16 as well as the anterior jig technique by Victor Lucia17 are found to be successful
and easily reproducible.
The technique used in the case-example of this chapter is a variation of the Lucia’s
JIG, called “jig and pin” (JP), because provides for simultaneous preparation of an acrylic
plane attached to the maxilla and a pin between the mandibular central incisors (Fig. 9a-b).
With the possibility of free movement on the horizontal plane, without dental contact
to trigger defensive positions against prematurities, tracing will indicate the border limits on
the most relevant plane of the movement of the jaw, at least as regards occlusion.
If one reminds the study by Ulf Posselt,18 it is on the horizontal plane that teeth will
touch and work. Knowing that the simple rustling of the teeth works as an activator or in-
terrupter of muscle activity,19 the free registration of myoneural reaction postures other than
the mandibular elevation allows us to find an easily reproducible starting axis.
When the JP device has been installed on the dental arches, one can ask the patient
to repeatedly occlude. The initial contact may be wandering. However, with repetition of
the movement there is a tendency to generate a single point of contact. At this point, one
can interpose a carbon tape and graphically mark the spot (Fig. 10).
The right and left movements of lateralization, and the protrusive mandibular move-
ment, can be recorded. One can use different color-coded carbon tape to differentiate
movements with and without manipulation. The degree of coordination and range of mo-
tion can in this manner be merely evaluated through plotting (Fig. 11).
204
Figure10. Figure11.
Figures 9a-b. Manufactured in self-curing acrylic, with the help of an ovoid glass plate, to make the incisal plane in the maxilla, and the help of the fingers, for fabricating a pyramidal pin between the lower
central incisors, the jig and pin allow for to outline the limits of the mandibular movements in the horizontal plane, with the interposition of a tape or occlusal contact marking film.
Figure 10.The central point is marking the point of coincidence of three unguided consecutive contacts, recorded with an interposed carbon tape. This may or may not be the posterior hinge of
the mandibular movement. Often, it is possible to manipulate the jaw so as to obtain a more distal position, that when forced may be recorded graphically, but not necessarily serve to establish the
maxillomandibular relationship of the work.
Figure 11. From this point, the lateral movements occur without hesitation or mishaps. The same may not be inferred from the protrusive movement. The tracings generated by three consecutive records
are shown as oscillatory (blue arrow).
Considering that the condylar position of maximal muscle elevation may be an ideal
RECORDING THE
WORK RELATIONSHIP
BETWEEN MAXILLA
AND MANDIBLE
position for determining the highest number of simultaneous occlusal contacts, it should
kept in mind that not always the occlusal registration results in obtaining this position. At
this moment, auxiliary techniques such as the bimanual manipulation of Dawson and CT
images appear to increase the degree of registration accuracy.
The option of using double # 9 wax rolls for recording the maxillomandibular rela-
tionship, as advocated more than 40 years ago by Arne Lauritzen,5 is due to the simplicity
and high effectiveness of the technique (Fig. 12).
Using the jig and post, even considering that the position of the greatest retrusion
condylar is graphically obtained when the patient is instructed to occlude with the interpo-
sed wax, it is expected that the lifting muscles or the strength of bimanual manipulation,
is capable of bringing the heads of the jaw to the highest possible position, in which the
greatest number of occlusal contacts should occur.
205
Figure 12.
SAGITAL VIEW - RIGHT SIDE
SAGITAL VIEW - LEFT VIEW
Figure 13a.
SAGITAL VIEW - RIGHT SIDE
SAGITAL VIEW - LEFT VIEW
Figure 13b.
Figure 12. Registration with the pin touching the jig in the distal vertex of the marking. The lifting muscles of the patient or Dawson manipulation allow
to position the mandible heads more superiorly. Things that must be clear: the result of this record will not necessarily be used to find the maximal
intercuspation. The depicted position is, first of all, an orthopedic position.
Figure 13a. On examination with the jig and interposed pin and patient activating the lifting muscles, it can be seen the intrusion of both heads of the
jaw towards the fossa roof, even with the interincisal clearance. This position, once transferred to an articulator, allow the verification of initial tooth
contacts and deflections that the jaw will make in pursuit of a larger number of occlusal contacts in maximum intercuspation.
Figure 13b. On examination with the patient in maximal intercuspation, we see both a more anterior and lower position of both heads of the jaw.
Imagining that the space interincisal decreased while the increased intra-articular space, one should consider that there was a mandibular torque
around a dental posterior fulcrum. Understanding this phenomenon is of paramount importance to the findings in the semi-adjustable articulator.
206
The patient model in this case seems to be very illustrative: it is possible to clearly identify the habitual closing position
that is not easy to be “deprogrammed” and a more distal position (Fig. 11). So the question arises: which of the two points
should we consider for repositioning the maximal occlusion? In this situation a CT in TRA and maximum intercuspation
positions may be valid. Any excessively posterior position would imply retrodiscal tissue compression, which should be
avoided.
Considering the espherographic registration occurs with pantographic bows or digitally, there is very important infor-
mation for correctly diagnosing the mandibular mechanics. However, this chapter is addressed to a group of professionals
who essentially do not believe that the use of a simple semiadjustable articulator is relevant to rehabilitate a smile.
It is not recommended to use CT scans to verify the joint position resulting from the registration with the jig or bima-
nual manipulation. However, for illustrative purposes, the model patient was submitted to two different CTs: one at maximal
intercuspation; and another with the jig and drill interposed (Fig. 13 a-b).
The relevance of using the face bow to register the correct positioning of the maxilla relative to the skull may be ques-
REGISTRATION OF THE
CRANIOMANDIBULAR RELATION
tioned. Once again it is worth questioning: if to apply an ear facial bow and obtain a very effective cephalometric registration
takes less than one minute, what is the merit of not using it?
The care to be taken is in rightly aligning the facial bow, in relation to the skull and face of the patient. This alignment
should be routinely verified along the three following planes: frontal, sagital and coronal (Fig. 14a , 15 b-c). It is a source of
error to make this type of registration the fake laying of the intra-ear olive and the nasion rod (N).
Figure 14a. In the frontal plane, the facial bow must pass parallel to the imaginary line that would unite both orbital points (Or). It is common in this type of instrument that the N point is marked in a standard
height bar. In cases of too much dolicocephalic or brachycephalous patients, we can ignore the nasion stem and place the arc in relation to the line Or-Or.
Figure 14b. In the sagittal plane, the positioning of the intraaural olive is the closest support of Porion point (Po). Thus, bilaterally guided by Po and Or points, the facial bow would approximate the Frankfurt
plane.
Figure 14c. In the horizontal plane, it should be noted the centralization of the bow. The intercondylar distance measurement is optional. When we are dealing with the rehabilitation planning in wax, there
will be the opportunity to better explain the option of using the average values for both intercondylar distance and the Bennett angle.
207
THE FIRST CONTACT
ANALYZING THE
MODELS MOUNTED IN
THE ARTICULATOR
During the analysis of a pair of stone models mounted in an articulator, if the maxillo-
mandibular registration and the assembly itself were carried out correctly, the first contact
or couple of contacts in TRA should be easily found. Once the locks of that position are
released, one must also find the position of maximal intercuspation (MI). Where it is impos-
sible to establish MI, two situations may have occurred: either the individual moves the jaw
distally to quit TRA towards MI,20 hich usually occurs with patients presenting Angle Class
II division 2; or the mounting is incorrect. Anyway, in these cases making a new registration
and reassembly of the models are valid.
After the verification of the accuracy of registration and the mounting of the models,
the occlusal analysis in the articulator is initiated. With the condylar latches activated, the
upper hive is closed on the base, and the first occlusal contacts are looked for. Typically,
these initial contacts occur on the last teeth of the arches: third, second or first molars.
Often one side will show contacts before the other. When there is this type of situation,
one may ask the patient which side they prefer while chewing. Unsurprisingly, the patient
reports that it is the first contact side. The patient model illustrates very well this type of
situation (Fig. 15a-b).
Figure 15a. The record with jig, pin and wax rolls allowed to establish an axis of rotation, to be transferred to the articulator, defined a closure arc, and consequently, the first occlusal contact. This is a
possible biomechanical position and, more than that, a likely position. Analysis of wear facets generated by this first contact, on models and straight in the mouth, is enough.
Figure 15b. On the contralateral side until the initial touch, the teeth fluctuated. In mouth, the absence of contacts on the right side will trigger a mechanism of neuromuscular adaptation. In fractions of a
second, the mandible will move forward and bend in pursuit of tooth stability. This reflex, yet little studied, will affect the muscles, ligaments, teeth and the coordination of movements; not only of the mouth
but in the whole body movements.21
208
Once the first occlusal contacts in the terminal axis of rotation is detected, one
THE
OCCLUSAL
LEVERAGE
should unlock the condyles of the articulator (if the equipment enable this feature)and ob-
serve the mandibular path until the greatest number of occlusal contact is achieved. The
greater the distance to be covered, the greater the joint rocking and, consequently, the
greater are the deleterious levers to the system. Using the case-patient model one can
illustrate this kind of occurrence (Fig. 16a-b).
Figure 16a. The first contact with the jaw by rotating the terminal shaft occurred between the third left molars, which led to an anterior open bite.
Figure 16b. Once released the condylar locks and the maximum interdigitation is achieved, it was observed that the bite opening moved to the joint region. This true occlusal teeter is the “exercise”
unconscious which the individual performs, whether awake or asleep, and that present a risk to the system in that it allows the changing patterns of levers and destructive overloads.
In cases of severe coronary destruction by attrition, much is said about the loss of
THE VERTICAL
DIMENSION OF
OCCLUSION (VDO)
the vertical dimension of occlusion. However, by knowing the compensation mechanisms

of wear by tooth eruption,22 it can be concluded that the “dimension which determines the
OVD is located in the elevatory muscles and their repetitive length of mandibular closure”.23
However, the occurrence of the occlusal rocking described above allows for a discussion:
the occurrence of a rocking that will switch the distance between the anterior teeth and
the spacing between the condyle head and the mandibular fossa, with the dental posterior
region as a fulcrum point or area and without necessarily changing the length of the ele-
vator muscles, the concern with the vertical dimension of occlusion, with the articular and
muscular vertical dimension that is required.
This reflection will be very important when formulating an occlusal rehabilitation pro-
ject, where the main objectives are the reduction of the articular gap and obtaining room
for the anatomical rebuilding of the dental crowns, with the remaining the length of the
lifting muscles of the jaw virtually unchanged.
209
After the verification of the contacts of the terminal axis of rotation and the contacts
THE LATERAL AND

PROTRUSIVE MOVEMENTS
AND PRODUCTION OF LEVERS
at maximum intercuspation, the analysis of the protrusive and lateral movements are left.
In this analysis, a relevant variable is the slope of the condylar guidance. Of the possible
individualization in a semiadjustable articulator, this is which has the mostl potential of
influencing the disocclusion of the posterior teeth. Therefore, it is recommended that in
some cases it is checked. Some techniques for recording and transporting these figures
to the articulator include an occlusal registration with wax or silicone while the mandible
is in eccentric positions, the evaluation of images as panoramic radiographs or CT scans
and also a simple direct measurement, in the patient’s mouth, of the degree of disocclu-
sion generated in border movements and the production of wear facets.24
As shown by Williamson,19 the absence of posterior contacts in protrusive and lateral
movements may relax the lifting muscles of the mandible. Then, the presence of these
contacts during the excursive movements may not only increase muscle activity but can
also modify the type of leverage generated by the system. It is noted that in cases such
as that shown the fact of having a side that shows a contact before the other during the
terminal rotation axis is enough for the appearance of a class I lever system, similar to a
crowbar in the frontal plane (Fig. 17a-b).
A similar phenomenon occurs when there is posterior contact in the balancing side
during the lateral movements. The closing action on the working side and the presence
of a posterior fulcrum allow the first type lever to appear as well as in the sagittal plane.
Figure 17a. During the mandibular closure in the terminal rotation axis, the first contact between the last molars on the left side starts to function as a fulcrum point. With the continuing movement, until the
teeth touch on the right side, a type I lever system is generated and the work applied to the left articulation (Figure 17b. Orange arrow).
210
As stated earlier, the occlusal diagnosis is the result of the analysis of the state of
THE FINDINGS OF AN
OCCLUSAL DIAGNOSIS
the teeth and the periodontium, evaluation of the state of muscle hyperactivity, the state of
articulation commitment and biomechanical possibilities of the system.
Only after consideration of these variables is that you can offer some form of therapy.
In the example shown, prior to the formulation of any treatment plan, the dentist should
know what is being treated. In this situation, tooth wear occurs, pain triggering points
upon palpation of both masseter muscles as well as in the anterior temporal and pterygoid
muscles, signs of fatigue and hyperexcitation in the electromyography, signs of anatomical
changes in the joints, without forgetting the main complaint of the patient, “my smile is
bending”. That is symptoms occur! In this case, as in other cases with patients seeking
treatment with complaints of an aesthetic nature, symptoms of pain, if any, are placed in
the background, but the occlusal diagnosis needs to go beyond the appearance of the
smile. It is necessary to identify the causes of the imbalance and the deterioration of the
system, and thus propose therapies and prognosis.
The presence of occlusal rocking described in the patient model may play a role in
the imbalance of crown destruction process. What is worse, upon reaching the maximum
intercuspation, there would be little or no disocclusion generated in the shear movements,
ie the musculature is unable to be deactivated due to the absence of contacts. However,
it must be clear that this imbalance is not the only or the major risk factor of alveolar bone
destruction. If it was possible to attribute any priority to the genesis of this pathology, there
would be the need to also look at microbiological, neurological, psychological, behavio-
ral, and yet social factors.
In the case of this patient, there are biomechanical, aesthetic, tender and degene-
rative signs indicating the need for intervention. Remember if there is the appearance is
the only reference value, after the treatment completed there is the risk of facing, further
complications, which may compromise the aesthetic result. The same applies to the isola-
ted treatment of each of the above factors. A treatment that focuses solely on the biome-
chanics can not neglect the final appearance of the work. The elimination of pain will not
necessarily stop the degenerative progress. A comprehensive diagnosis will reduce the
risk of specific and ineffective treatments.
Now there is a question: can the occlusal balance reduce the risk of the progression
of the alveolar bone destruction?
This is an issue undoubtedly not answered. The scarcity and difficulty of performing
analytical longitudinal studies on the subject, there exists little evidence that occlusal reha-
bilitation is sufficient enough to stop the degeneration process of the system. However,
a sectional cohort study with a population of patients with periodontal disease, with and
without discrepancies along with occlusal adjustments after the occlusion, with a 15-year
follow-up have indicated a clear relationship between the occlusal mismatch and the pro-
gression of periodontal disease.25
However, with an eminently clinical view, it can be said that an occlusal rehabilitation
which provides balanced and simultaneous contacts, without or with a minimal articular
offset during the maximum bite, and without contacts on the posterior teeth during lateral
and protrusive jaw movements is capable of increasing the patient’s occlusal comfort.
211
There are means of measuring this increase in comfort. Contact sensors associated
with electromiographs are able to quantify the occlusal contacts while the muscle behavior
(masseter and anterior temporal bundle) is tracked.25 The occlusal diagnosis carried out
from stone models mounted in articulator along with the terminal rotation axis relationship
identify the degree of mandibular rocking, as well as the degree of disocclusion generated
during the excursive movements of the mandible. This diagnosis should be the starting
point for any rehabilitation proposal.
For reasons of neuromuscular programming, via dental proprioception, disocclusion
in rehabilitation should be generated. For generating disocclusion is necessary to establish
the vertical overlapping (overbite) as well as inclined planes that do not inhibit sliding of
the teeth. For a biomechanical matter, one should position the dental contacts and con-
sequently the mandible so that the first and second type levers are eliminated or at least
mitigated and, once said alignment has been achieved, it is possible to equally distribute
the dental contacts axially.
After reproducing the orthopedic relation of the mandible to the maxilla in the articula-
DESIGNING
THE OCCLUSAL
REHABILITATION
tor, one should seek the alignment of the teeth. Clinically, it is possible to achieve balance
and harmony in this alignment through movements, wear or by increments.27 When the
professional encounters models in the articulator, it remains to trim the cast or add wax,
to obtain the axial distribution of occlusal forces and disocclusion. Therefore, great impor-
tance is attributed to the occlusal diagnosis. Early identification of situations that can best
be solved with orthodontic or even surgical movements, can save time, pain and money.
Using the case of the patient, an occlusal reconstruction sequence in the articular
simulator is demonstrated. For this purpose, the principle of sectorization by tooth qua-
drants is applied. The relationship between incisors and canines is restored, to establish
later the most appropriate anatomy for the posterior teeth.
The advantages of initiating the occlusal rehabilitation design through the establish-
ment of an anterolateral guidance is to take advantage of the proper ratio of dental shapes
and its consequent aesthetic predictability until the possibility of establishing slide pa-
ths absolutely harmonious with the articular displacement, without producing rocking nor
mandibular leverages.
212
By locating the terminal position in the right and left joints, the posterior axis is esta-
ALIGN THE
MANDIBLE, THEN
ALIGN THE CANINES…
blished. While the location of the contact between the maxillary and mandibular canines
from both sides establishes a locking anterior axis. The idea is to obtain a chassis or a
polygon where the remaining teeth will be positioned.
Another issue that may already be solved with the alignment of the four canines is
obtaining the vertical dimension of occlusion.
For these solutions to be feasible, one should take hold of the principle of proportio-
nality between the teeth. Starting with the use of the table of forms and size of the teeth28
it is possible to restablish dimensions of width to height for a posterior orientation (Fig. 18).
Cervico-
incisal
Root
M-D
M-D
neck
B-L
B-L
neck
Cervical
M
Cervical
D
Figure 18.
Figure 18. Table with average values in mm for the measurements of permanent teeth, the most important measures are the length and the
mesiodistal diameter of the crowns. The values presented here were compiled from The Atlas of Permanent Teeth Anatomy (Fioranelli and
collaborators).
213
For example, in the case presented, the mesiodistal dimension (MD) of the teeth 43
and 33 was 7.3 mm. One can use the table and with a simple rule of three, calculate the
height of the crowns of these mandibular canines: if 7mm MD results in a crown with 11
mm of cervicoincisal (CI) length, 7.3mm corresponds to a crown of X mm of cervicoincisal
(CI) length. In this example, X= (7.3 x11)/7, which results in a crown height of 11.47 mm
for the mandibular canines.This same reasoning is applied to the maxillary canines.
Based on the values obtained, the dimensions of the four canines must be rebuild.
After the reconstruction, the coupling and the overlapping obtained are checked. When
bilateral, simultaneous contacts do not occur with the elimination of the mandibular rocking
(a posterior contact does not permit any contact between the canines), one should decide
whether the size of the canines will be increased or grinding the posterior contact point will
be required. In the case described the simple reconstitution of shape and size of the teeth
was enough to put an end to any of the rocking effect of the mandible (Fig. 19).
COMPLETE
THE INCISAL
GUIDE
Following the establishment of the vertical and lateral relationships of the mandible
in relation to the maxilla, one may focus on the incisor teeth. Typically, we accomplish
the anterior lower teeth. Then we build the maxillary incisors, first the centrals and finally
the laterals. Again, the concept of proportion is applied therein (Fig. 20). As mentioned in
section 2, the interpupillary distance may be used to obtain an aesthetically ideal width for
the central incisors as well as through an aspect ratio, the height of the teeth #11 and #21
which also have been obtained. Often, with the application of different calculation methods
the optimal size of our crowns are obtained, it is possible to achieve very similar results.
After the anterior guidance determined, one should take care of the vertical stability
COMPLETE THE
PROJECT WITH
THE POSTERIOR
TEETH
when the lifting musculature of the mandible is triggered by the repetitive length of maxi-
mum contraction. Explaining better, the posterior contacts with the heads of the mandible
lodged the most superior in relation to the fossa as possible are created. In the case of the
articulator, this position should be located at the locked terminal axis position.
Where appropriate, there are situations in which the alignment discrepancy between
the upper and lower arch is greater than the anatomical range of variation which one can
use, namely: where it would be necessary to further distort the dental anatomy to provide
coincidence between the maximum and dental occlusion mandible heads accommoda-
ted in the ceiling of the respective fossa. When the oscillation is exaggerated, alternative
therapies such as orthognathic surgery may be suggested. One may also perform tooth
reduction and orthodontic movements, but it must be clear that the difference between a
terminal condylar axis and maximum intercuspidation should be minimized under the pe-
nalty of increased risk towards the onset of temporomandibular disorders29 and increased
risk of occurrence of occlusal disease itself.
214
On the other hand, it is believed to be unacceptable displacements minor than 1
mm, especially if they occur only in postero-anterior direction.It is believed also that the hi-
gher mechanical stress on the entire dentition and occlusal system occurs unconsciously,
and most of the time, while asleep. Therefore, the use of an occlusal orthosis (plate) may
be indicated by aligning teeth and mandible in overloading situations.
The patient model again illustrates this type of occurrence. The displacement of the
intercondylar axis from the centric position to the maximum tooth contact position can
not be completely eliminated only by changing the shape of crowns of teeth. It would be
necessary to create true anatomical aberrations to enable such the condylar-occlusal lo-
cking. So it was created a project in wax which reduced the slide of the terminal axis from
3.0 mm to less than 1.0 mm. Greater than that, the displacement was guided. If this earlier
generated first or second degree levers, after reconstruction by wax-up, condylar sliding
occurred along the surface of the articular eminence, avoiding rocking (Fig. 21).
Figure 19. After the anatomical reconstruction of the crowns of the four canines and the upper branch of the articulator locked onto terminal axis of rotation, it was possible to eliminate any rocking or teeter
movement of the jaw. The next step is to check the generated overbite. In the case of canines, this overlap may be 3 to 5 millimeters, and must allow disocclusion of the posterior teeth to occur during the
lateral movements. The obtained maxillomandibular vertical relationship should be maintained until the end of wax-up. This will be the vertical dimension of occlusion of the rehabilitation.
Figure 20. The reconstruction in wax of the anterior guidance is tried during protrusive movement. Being the incisors in a top relationship, the upper branch can be guided laterally and simulate shear. This
maneuver also repeated on the lateral guidances by the canine teeth, allows for a functional adjustment.
Figure 21. Occlusal rehabilitation project completed. Current technologies allow for testing the application of this design in an absolutely reversible and changeable manner.
215
After the occlusal diagnosis, which considered the orthopedic articular axis, the con-
EVOLVING THE
DESIGN FOR
REHABILITATION
tact of teeth, the neuromuscular balance (or imbalance) and the spatial relations between
the maxilla and mandible, and after the construction of an occlusal rehabilitation project
(ORP), the operatory part is reached, namely transporting the project to the mouth. Cur-
rently, by combining bonding techniques with bis-acrylic polymers, it is possible to carry
what had been determined on the lab bench to the mouth in less than 4 hours of clinical
time. This is when the professional is convinced of the value of spending so much time
with the diagnosis and the design. The treatment becomes most accurate, from both a
biomechanical as well as from an aesthetic point of view. The permanent rehabilitation
assay (PRA) is an absolutely reliable way to achieve a long lasting occlusal rehabilitation.
For performing a PRA, waxing is initially duplicated with materials such as silicones or
alginates. Specifically in the case of a PRA, one may use a laboratory PVS material (Plati-
num®, Zhermack, Italy) directly on the waxed models. With the aid of pressure chambers,
where it is possible to inject compressed air during polymerization, allowing for extremely
precise and detailed guides to be obtained (Fig. 22).
As a complement, alginate may be used for duplicating and obtaining the wax-up
and stone replicas. On these new models, one may fabricate 0.3 mm thick acetate masks
(BioArt®, Brazil) in a vacuum-forming machine. These mask molds have several utilities.
They serve for visualization of the extent of the reconstruction, to guide the preparations
toward maximal preservation of the remaining tooth structure and further, as molds to be
filled with any plastic material which is suitable for reproducing a tooth (Fig. 23).
Figure 22. PVS walls (Platinum® 85, Zhermack) polymerized under pressure of 2 bar. The capability of detail reproduction in a tough, stable and flexible matrix becomes the greatest ally during the occlusal
reconstruction, be it plastic with acrylics, bis-acrylic or composite resins.
Figure 23. Acetate shells prepared from the waxed stone model or obtained through mock-up impression.
216
Being able to transfer the occlusion of the patient through a mechanical simile is the
THE OCCLUSAL
PLASTIC
great asset of this technology. Therefore, the possibility of transporting the result of a project
designed on the laboratory bench and back to the patient’s mouth is the basis of the work
proposal of this chapter: the plastic occlusal rehabilitation. It is understood that once the final
form of the reconstruction is defined, the material which was used becomes a secondary
factor. It most likely will not work with plastic materials, nor with prosthetic solutions.
Therefore, it was described how to rehabilitate an occlusion almost instantly through
the use of PRO, silicone walls, acetate shelves, bis-acrylate and composite resin.
In the model case used to illustrate this chapter, the plastic rehabilitation will be repla-
ced by a laminate job using high translucency leucite (IPS Empress® CAD, Ivoclar Vivadent,
Liechtenstein) and a nanoceramic resin (Lava Ultimate®, 3M ESPE, USA), using the biocopy
option of the Cerec system (Cerec®, Sirona, Germany). That is, the anatomy obtained in wax
will be transferred to the mouth of the patient with the use of plastic materials and will be later
replaced by longer lasting and more stable materials.
In a way similar to the wax-up, this process is initiated in the anterior-inferior sector
(sector I). With the aid of polytetrafluoroethylene tape, the segment is isolated and etching is
performed only on the incisal third of the teeth (Fig. 24). After rinsing, a multipurpose adhe-
sive (Single Bond Universal®, 3M ESPE, USA) is applied, light cured, and a bis-acrylic resin
(Protemp® 4, 3M ESPE, USA) is then applied (Fig. 25 and 26).
After the initial polymerization, the silicon wall is removed and separation and individu-
alization of the teeth is performed (Fig. 27 a-b).
Figure 24. The bonding promoted merely in the incisal third of the teeth allows for to the reconstruction strength and stability and yet, facilitates the future removal.
Figure 25. With the aid of the gun and the specific mixing tip, the activated bis-acrylate is dispensed in the silicon wall, in the corresponding area from incisal to cervical. Then, the impression is taken to the
mouth. It is expected 2 to 3 minutes until the initial polymerization to occur.
Figure 26. After removing the silicone impression, the coarser cervical excesses are removed and finishing and individualization of the teeth are carried out.
Figures 27a-b. Ceri-Saw blade handle (DenMat®, USA), diamond discs (Komet®, Germany) , diamond points and multilaminated steel burs (Komet®, Germany and KG®, Brazil) are used to promote the
individualization of teeth.
217
Figure 28. If the interocclusal record and mounting of the models in the articulator was careful, if the wax-up was meticulous, as well as the construction of the guides in acetate and silicone, if the
application of rehabilitation materials (in this case, bis-acrylate) was diligent, the designed fit for the anterior guidance should be found (segments 1 and 2).
Figure 29a-b. Identical to the segments 1 and 2, when applying bis-acryl on segment 3, bilateral inferior-posterior, selective bonding is performed previously, concentrated in the area that should receive
more occlusal loading.
Figure 30a-b. With the aid of selective bonding, composite resin veneers (Z350® XT XWE, 3M ESPE, USA) are instantly made.
Figures 31a-c. With the occlusal plastic in bis-acryl, the patient could test the arrangement established during the planning of the case, not only in the aesthetic sense, but especially in the biomechanical
sense. The final treatment for the case could wait for weeks to be sure what we is being made.
218
Upon completion of the segment corresponding to the six anterior-lower teeth, the
same steps are repeated in the antagonist, ie, the anterior superior teeth (Fig. 28). Due to
the aesthetic role performed by this segment one must be be prepared for anatomical chan-
ges by additioning or removing after the polymerization of the wax-up copy. This appears to
be the major advantage of this method: the ability to test a rehabilitation design in all of its
occlusal, aesthetic and phonetic aspects, and most importantly, to be able to make in loco
changes at any moment.
During the planning of the rehabilitation of the patient model, it was decided that the
entire occlusal addition would be carried out on the posterior mandibular teeth. This option
was taken due to little available interocclusal space, especially between the molars on the
left side (Fig. 29a-b).
To further illustrate the possibilities of implementing a plastic occlusal rehabilitation, in
the treatment sequence of the patient-model, we chose to use acetate shelves in combi-
nation with composite resin (Z350XT® XWE, 3M ESPE, USA) (Fig. 30a-b). As informed ear-
lier, in the posterior-superior teeth (Segment 4) occlusal additions would not be necessary.
Composite resin veneers, along with selective bonding, are to complement the planned
arrangement.
At the end of the plastic rehabilitation, a new arrangement is obtained. The mandible
is repositioned, the teeth are reshaped, and the muscles reprogrammed. This new anatomy
may be replaced in an intensive or progressive manner. In the case of patient-model, an
entirely CAD/CAM job awaits. But that’s just technology. With the recovered shape, there will
be more and more ways of keeping it (Fig. 31a-c).
THE COPYED
REHABILITATION
It is not within the scope of this chapter the description of the restorative technique.
However, it is necessary to illustrate the finalization of the work. As stated earlier, once
the final form of rehabilitation has been established, it may be copied with more durable
or aesthetic materials. In the case described in this chapter, the bis-acrylate rehabilitation
remained in the mouth over 45 days. During this period, the patient could test the job in all
of its aspects: biomechanical, aesthetic and phonetic.
After the test period, with the aid of a CAD/CAM system (Cerec®, Sirona, Germany),
the interim bis-acrylic rehabilitation was gradually replaced. In the maxillary and mandibular
anterior teeth, all-ceramic leucite-reinforced B1-colored high translucency partial laminates
(IPS Empress® HT B1, Ivoclar Vivadent, Liechtenstein) were obtained by biogeneric copy
and milling.Extrinsic characterization and glazing were carried out, and cementation (+2
Value, Variolink Veneer®, Ivoclar Vivadent, Liechtenstein] (Fig. 32 to 36).
In the posterior mandibular teeth (from the first premolars to the second molars) ge-
nuine occlusal ceramized resin veneers were fabricated (Lava Ultimate® HT B1, 3M ESPE,
USA). The biogeneric copy process was also employed, and the cementation of these
pieces was performed (RelyX Ultimate®, 3M ESPE, USA) (Fig. 37 to 39).
219
Figure 32. Figure 33a.
Figure 33b. Figure 34. Figure 35.
Figure 36.
Figure 32. After scanning the contour of the bis-acryl, the teeth can be prepared and then scanned again. The crown or veneer will be the copy of the original contour of the “unprepared” tooth.
Figure 33a-b. The final virtual design of a double veneer and the milled veneer. During the design, the insertion axis can be virtually tested.
Figure 34. A faithful copy of the design sculpted by the Cerec system® (Sirona, Germany) previously treated and ready for adhesive cementation.
Figure 35. The lower segment also labored in IPS Empress® CAD system (Ivoclar Vivadent, Liechtenstein), copied the shape of the rehabilitation trial.
Figure 36. Result after the adhesive cementation of the maxillary and mandibular anterior teeth.
220
Figure 39.
Figure 37. The preparation of the occlusal veneers was accomplished on the restorative bis-acryl test. Note that the mere thickness of the bis-acryl already allows for prosthetic restorations. At this point,
preserve the enamel-dentin junction should be an obsession.
Figure 38. Finalized the preparations, the maximum enamel is maintained. The cervical restorations were also preserved in order to allow for insertion axis of the final restoration.
Figure 39. The double veneers (occlusal-buccal) after finishing, characterizations and final polishing.
One may consider the main objectives of the occlusal rehabilitation to be the es-
tablishment and recovery of the beauty of a smile and the comfort of mastication. The
binomium function and the aesthetics are repeated to exhaustion and frequently stops
making sense for Dentistry. It is expected that this chapter has illustrated the indissoluble
relationship between morphology and dental performance. When comparing the initial and
final smile (Fig. 40a-b) the intraoral pictures (Fig. 40c), and reviewing the patient’s report of
comfort while chewing increased considerably, it may be concluded that all of the goals of
treatment at this magnitude were fully achieved (Fig. 41a-g).
221
Figure 40c.
Figures 40a-c. The comparison of the initial and final photos leave no doubts as to the aesthetic gain. However, treatment will only be fully justified if there is gain in performance, and balance and comfort
of chewing as well.
Figures 41a-f. Initial facial photographs for comparative analysis and final photos after cementation of overlays (Lava Ultimate® CAD/CAM, 3M ESPE, USA) and installation of ceramic veneers (IPS Empress®
CAD, Ivoclar Vivadent, Liechtenstein) with palatal extension for the maxillary and mandibular anterior teeth, demonstrating an aesthetic rehabilitation based on principles and aesthetic references, as well as
a long-lasting functional rehabilitation. Photographs taken by Dudu Medeiros.
222
223
224
1. Lyttle J. The Clinician’s Index of Occlusal Disease: definition, recognition, and management. J Perio Rest Dent.
REFERENCES
1990;10(2):102-23.
2. Sato S, Sasaguri K, Ootsuka T, Saruta J, Miyake S, Okamura M, et al. Bruxism and stress relief. In: Onozuka M, Yen CT,
editors. Novel trends in brain science: brain imaging, learning and memory, stress and fear, and pain. Tokyo: Springer; 2008.
p. 183-200.
3. Magne P, Gallucci G, Belzer U. Anatomic crown width/length ratios of unworn and worn maxillary teeth in white subjects.
JPD. 2003;89(5):453-61.
4. Buonocore M. A simple method of increasing the adhesion of acrylic filling materials to enamel surfaces. J Dent Research.
1955;34(6):849-53.
5. Lauritzen AG. Atlas de analisis oclusal. Madrid: H.F. Martínez de Murguía; 1977.
6. Moyers RE. An electromyographic analysis of certain muscles involved in temporomandibular movement. Am J Orthod.
1950;36(7)481-515.
7. Pereira M. Saúde e doença. In: Epidemiologia: teoria e prática. Rio de Janeiro: Guanabara Koogan; 1995. p. 30-48.
8. Nakata M. Masticatory function and its effects on general health. Int Dental J. 1998;48:540-8.
9. Huynh N, Kato T, Rompré PH, Okura K, Saber M, Lanfranchi PA, et al. Sleep bruxism is associated to micro-arousals and an
increase in cardiac sympathetic activity. Sleep Res. 2006;15(3):339-46.
10. Bartlett D. The role of erosion in tooth wear: etiology, prevention and management. Int Dental J. 2005;55:277-84.
11. Sobral MAP, Luz MAAC, Gama-Teixeira A, Garone Netto N. Influência da dieta líquida ácida no desenvolvimento de erosão
dental. Pesqui Odontol Bras. 2000;14(4):406-10.
12. Grippo JO. Abfractions: a new classification of hard tissue lesions of teeth. J Esthet Dent. 1991;3:14-9.
13. Dawson P. Occlusal disease in funcional occlusion. St. Louis: Mosby; 2007.
14. Christensen LV, Donegan SJ, Mckay DC. Temporomandibular Joint: vibration analysis in a sample of non-patients. J Cranio-
mandib Prac. 1992;10:35-41.
15. Gervais R, Fitzsimmons GW, Thomas NR. Masseter and temporalis electromyographic activity in asymptomatic, subclinical,
and temporomandibular joint dysfunction patients. J Craniomandib Prac. 1989;7:52-7.
16. Dawson P. Position paper. In: Celenza FV, Nasedkin JN. Oclusion: the state of the art. Chicago: Quintessence; 1978.
17. Lucia VO. Position paper. In: Celenza FV, Nasedkin JN. Oclusion: the state of the art. Chicago: Quintessence; 1978.
18. Posselt U. Physiology of occlusion and reabilitation. Oxford: Blackwell Scientific; 1968.
19. Williamson EH, Lundquist DO. Anterior guidance: its effect on electromyographic activity of the temporal e masseter muscles.
J Proth Dent. 1983;49(6):816-23.
20. Ren YF, Isberg A, Westesson PL. Condyle position in temporomandibular joint: comparison between asymptomatic vo-
lunteers with normal disk position and patients with disc displacement. Oral Sur Oral med Oral Oathol Oral Raiol Endod.
1995;80:101-7.
21. Muratsu K, et al. Remarkable improvement of persistent period of time under standing on one foot with closure of eyes by
dental occlusion. Jap J Dent Health. 1997;4(27).
22. Berry D, Poole D. Attrition: possible mechanisms of compensation. J Oral Rehab. 1976;3:201-6.
23. Dawson P. Vertical dimension in functional occlusion. St Louis: Mosby Elselvier; 2007.
24. Dos Santos J, Nelson S, Nowlin T. Comparison of condylar guidance setting obtained from a wax record versus an extra-oral
tracing: s pilot study. J Proth Dent. 2003;89:54-9.
25. Harrel SK, Nunn ME, Hallmon WW. Is there is an association between occlusion and periodontal destruction?: yes, occlusal
forces can contribute to periodontal destruction. JADA. 2006;137:1380-92.
26. Kerstein RB, Wright N. An Eletromiographic and computer analysis of patients suffering from chronic myofacial pain dysfunc-
tion syndrome: pre and pos-treatment with immediate complete anterior guidance development. J Proth Dent. 1991;66:677-
86.
27. Alonso AA, Albertini JS, Bechelli AH. Oclusión y diagnóstico en rehabilitación oral. Buenos Aires: Médica Panamericana;
1999.
28. Vieira GF. Atlas de anatomia de dentes permanentes. São Paulo: Santos; 2009.
29. Maruyama T, Miyauchi S, Umekoji E. Analysis of the mandibular relationship of TMJ dysfunction patients using the Mandibular
Kinesiograph. J Oral Rehabil. 1982;9(3):217-23.
225
SECTION III. IMPLEMENTATION
ON THE SIZE | ON THE CERAMIC SYSTEM | ON THE IMPRESSION-TAKIING | ON THE PROVISIONAL RESTORATION
chapter 6.1
preparation for ceramic veneers
Rafael de Almeida Decurcio | Paula de Carvalho Cardoso | Lúcio Monteiro
Marcus Vinícius Perillo | Wilmar Porfírio de Oliveira | Terence Romano
Devised by Black, in 18914 the principles of “extension for prevention” for cavity pre-
INTRODUCTION
paration were designed for use with metallic restorative materials and being non adhesive,
out of the necessity for preparations with a geometric shape retention and resistance with
greater loss of tooth structure. However, the evolution of restorative materials and adhesive
systems driven by the insaciable social desire for aesthetic results gave birth a new dental
age, providing the manufacturing of all-ceramic restorations with functional, durable and
aesthetic results.8,37 These advances have allowed for the application of modern restora-
tive principles: (1) maximum preservation, (2) maximal prevention and (3) minimal wear.9,23
This new philosophy of “prevention for extension” seeks to minimize the biological cost of
the natural tooth as a whole43 and culminates in the modification of traditional preparations
and creation of a new classification for ceramic veneer veneers:
ON THE SIZE
• TOTAL: involvement of the entire surface (labial, palatal or occlusal)
WITHOUT PREPARATION: use of thin ceramic veneers (0.1 mm to 0.7 mm thick)
over the tooth structure with minimal or no wear, and strongly bonded to tooth ena-
mell.7 n this technique, the restorative design of ceramics are guided exclusively by
pre-existing defect in the tooth to be restored, as, for example, corrections of the
shape and incisal edge, fractured and conoid teeth, with small diastemata and paral-
lel walls, reestablishment of the anterior and/or canine guide, and vertical dimension
increase.
WITH PREPARATION: conventional veneers which require making preparations with
labial, proximal, incisal and occlusal reduction. Indications include teeth which are
proclined, rotated, misaligned, or discolored, replacement of defective composite
resin veneers and production of adequate prosthetic room in posterior teeth for in-
creasing the vertical dimension of occlusion.
• PARTIAL (fragment type): without involvement of the entire surface
WITH PREPARATION
WITHOUT PREPARATION
The longevity of rehabilitated cases with ceramic veneer veneers - most importantly
associated with the conservative concept of minimal preparations – became over the
years a great ally in the indication process. The high success rate of ceramic veneer ve-
neers observed in clinical studies is directly related to the bonding of the dental substrate,
especially enamel, which explains the need to preserve that structure.5,28 This means
that the greater the amount of enamel, the better the adhesion, and consequently, more
predictable and the longer lasting becomes the rehabilitation process. Ideally, the prepara-
tion should be confined to enamel, or maintain 70% of enamel on the surface, especially
along the preparation margins.33,36 Cementation failures which cause the displacement of
ceramic veneer veneers have been reported in preparations where 80% of the location
is made up of dentin. These failures are unlikely to occur when the minimum of 0.5 mm
enamel is present peripherically.19
230
The deepest preparations, as in proclined, misaligned, or discolored teeth with se-
vere occlusal wear can reach dentin and lead to lower bond strength values and poor du-
rability.10 In such situations, one must evaluate the thin line between choosing veneers or
crowns, as the presence of a substrate eminently in dentin tends to the need for additional
mechanical retention such as a crown preparation, which results in greater predictability
as well as the longevity of the treatment.38
It is worth remembering that a full ceramic veneer, with preparation, can still be con-
sidered a conservative treatment, since a full crown requires more sacrifice of tooth struc-
ture; therefore, whenever possible, one should expand the range of indications of these
veneers, by linking them to the conservation of tooth structure and high clinical success
rates.
Is worth mentioning that in the modern restorative concept two factors are crucial for
the success of ceramic restorations: understanding dental anatomy and vision of the final
restorative dimension. These factors should be considered before any mechanical dental
change.
The first consideration, the extensive knowledge of dental anatomy, can provide is
an objective basis for dental preparation. It is essential to have knowledge of the mean
thickness of enamel, because maintaining this structure implies superior bonding values
and increased longevity of the rehabilitation procedure. Whenever possible, given the
specificity of the case, it is essential for maximum enamel preservation as well as greater
predictability and longevity.1
The second consideration, the vision of the final restorative dimension, can prevent
extensive removal of tooth structure. The amount of tooth reduction must be carried out
according to the final anticipated volume of the contour of the restoration. The diagnostic
wax and the mock-up (Chapter 4) are essential to provide changes in the size, shape and
dental contour, providing the necessary dimensions of the desired preparations before the
restorative procedures.21,22 This technique offers a more conservative approach to cavity
preparation.
231
PREPLESS OR “CONTACT LENS”
PREPARATIONS FOR
ALL-CERAMIC VENEERS
The original concept was developed in 1938 by Pincus, which describes a technique
for masking defects and improving the appearance of the teeth for American actors using
plastic or porcelain veneers to be maintained by an adhesive solely during footage.
In the late 1970s, a prefabricated acrylic veneer, chemically joined to the tooth struc-
ture by a thin layer of self-curing composite resin was recommended by Faunce and
Myers.13
The concept of making and cementing porcelain veneers was introduced in the
1980s. While Horn25 described the procedures for manufacturing and cementation, the
studies of Simonsen and Calamia39 supported and provided the protocol data of the pro-
cedure and the time for the surface conditioning of the ceramics (hydrofluoric acid and
silane agent) to improve adhesion.
In the decades of the 1990s and 2000s, preparation for veneers were largely perfor-
med. 29,34
The assumption was to replace the amount of enamel prepared with a material
with a similar modulus of elasticity,6 one of the reasons for the success of this approach.
Currently, there is a philosophy guided by modern restorative principles: (1) maxi-
mum preservation, (2) maximal prevention and (3) minimal intervention. This last once
again stimulated the return of the luting approach of ceramic veneers with no or little wear
(in retentive areas).9,23 Although conceptually related to optics/ophthalmology and manu-
facturing mechanisms, using this term has nothing to do with Dentistry, the term “contact
lenses” was incorporated into the world of cosmetic dentistry, and ceramic veneer veneers
without wear are popularly known as such.31 Each and every sharp edges should be re-
moved in order to eliminate any potential structural stresses at the moment of the ceramic
seating. Average grit aluminum oxide based discs are the most suitable for carrying out
the smooth off the edges.
Indications for total ceramic veneer veneers without preparation are:
• corrections of the incisal edge (Fig. 1);
• fractured teeth (Fig. 1);
• conoid teeth (Fig. 2);
• diastemata with parallelism of the faces involved (Fig. 3 e 4);
• teeth with enamel loss by non shallow carious lesions (Fig. 5);
• teeth in need of labial volume increase for improved lip volume or orthodontic post
treatment with lingually placed crowns (Fig. 6);
• restoration of the incisal length to improve function (anterior and/or canine guide);
• occlusal restoration (Fig. 7); and
• tilting correction (labial-palatal) of contralateral teeth.
Contraindications for full ceramic veneers without preparation are:

• Insufficient superficial enamel;
• discolored teeth;
• proclined teeth;
• crowded teeth; and
• restored teeth.
232
Figure 1g.
Figure 1. Initial smile revealing the presence of interincisal diastema, Class IV restoration and presence of worn incisal edges (a); detail of the staining of class IV and III composite resin restorations
(distal) in tooth #11 (b);palatal aspect revealing the extent and staining of the Class IV restoration (c); frontal view after removal of class IV and III restorations (d); palatal aspect after removal of the
defective restoration (e); incisal view after cementation of ceramic veneers from 13 to 23. Observe the continuity and biomimetism reestablished by the ceramic (f) and the final smile demonstrating
naturalness. (g)
233
Figure 2b.
Figure 2. Initial facial aspect showing disharmony (a); Initial frontal smile with the presence of diastema between anterior superior teeth and conoid teeth(b), initial left (c), initial right (d); Initial intraoral
photograph revealing the details of the initial condition (e); prepless ceramic veneers or “contact lenses” cemented on teeth 13 to 23 (f); Final frontal aspect of the smile (g); Final left (h); Final right (i) and
final aspect of the face showing a state of total harmony and aesthetic and functional reestablishment.
234
Figure 2j.
235
Figure 3a. Figure 3f. Figure 3g.
Figure 3h.
Figure 3i.
Figure 3. Initial protocol photography for the initial facial analysis (a); Initial smile demonstrating gingival display greater than 3 mm and generalized diastemas (b); ideal exposure at rest for women (c);
note the parallelism of the diastema between the incisors and presence of teeth #14 and #24 slightly proclined (d); aspect of the smile after 120 days of periodontal surgery with flap raise-up from #16
to #26 (e); detail of whiter teeth after bleaching by the association of techniques (f); after new mock-up and approval of the patient, impression was carried out with no reduction of tooth structure and
preparation of ceramic veneers from 15 to 25 (g); frontal aspect after cementation (h); analysis at rest after rehabilitation with the total prepless ceramic veneers (i); final smile (j); and final aspect of the
face in total harmony (k); beauty as a whole (l). Facial photographs taken by Dudu Medeiros.
236
Figure 3l.
Photography taken by Dudu Medeiros.
237
Figure 4b.
Figure 4f.
Figure 4. Initial protocol photography (a), analysis at rest (b); Initial smile revealing multiple diastema (c); intraoral aspect with small spacing, and parallel to each other (d); result after cementation of full
ceramic veneers without preparation from 15 to 25 (e); details of vertical and horizontal texture reproduced in the ceramic veneer (f); final smile (g); final protocol photograph of the face (h); and the beauty
transmitted by the smile (i). Ceramist responsible: José Carlos Romanini. Photographs of the face by Dudu Medeiros.
238
Figure 4i.
Photography taken by Dudu Medeiros.
239
Figure 5b.
Figure 5f.
Figure 5 Smile frontal face shows aesthetic disharmony and aged aspect (a); Initial smile photo reveals dental darkening and curve not parallel incisal edge with lower lip (b); the intraoral photographs
confirm the dull aspect and generalized loss of enamel, caused by the habit of lemon sucking (c-d); aspect after cementation of the veneer of tooth #21. Notice that the “contact lens” restored lost
enamel (e); ideal analysis at rest with an average exposure of 3.4 mm (f); final radiant smile (g);facial photograph of protocol (h);and face with a new smile (i).
240
Figure 5i.
241
Figure 6b.
Figure 6d.
Figure 6. Initial protocol photograph of the face (a); Initial smile after orthodontics demonstrating that the spaces were distributed, however lacking tooth volume, the teeth are short and absence of any
dominance of the centrals (b); observe in the intraoral figure the presence of changed gingival contour (c); after mock-up, periodontal surgery, and bleaching, the impression for the manufacture of full
ceramic veneers without preparation was carried out. Notice that the “butterfly pattern” of the distal aspect of the centrals was selected to promote the optical illusion of broader teeth and hence higher
dominance for the centrals (d); Final smile revealing a new arrangement, younger and more radiant (e); final protocol photograph of the face (f); and art and naturally in the face, smile, teeth and gingiva
set (g). Facial photographs taken by Dudu Medeiros.
242
Figure 6g.
243
Figure 7.Young patient presented with aged smiling and lack of labial volume after orthodontic treatment.After thorough planning with facial analysis, there was skeletal deficiency, of familial background,
in the lower third, however without loss of the vertical dimension of occlusion. Note the presence of deficient composite resin veneers from canine to canine (a); Detail of the staining and poor shape
of the veneers composite resin (b); after removal of composite resins, there is the presence of widespread diastemas and conoid teeth (c); the taper of the diastema and conoide tooth favored the
realization of ceramic veneers without preparations with palatal involvement, aka “full veneers”. Thus, there was only the impression without any wear of tooth surfaces, and mounting on SAA for the
manufacture of occlusal ceramic veneers and “full veneers” (d); observe the details of the occlusal veneers extending towards the labial on the model without any preparation (e); detail for the “full
veneers” of teeth 11 and 21 (f); notice the thin occlusal veneers of the premolars extending towards the labial (g); result immediately after cementation (h); and final smile demonstrating naturalness and
youthfulness (i).
244
It is worth remembering that the final objective and the thickness of the restorative
material should be considered to avoid overcontour of the restored teeth. Another consi-
deration is the amount of masking required on the dental structure. Several discolorations
could require considerable thickness of restorative material and as a result, a more inva-
sive tooth preparation result and to determine the final thickness and morphology of the
tooth and of the restoration.
Some of the advantages of the prepless veneers in relation to conventional veneers
(with preparation) are the preservation of sound tooth structure, reduced clinical time for
the impression taking step, the elimination of the provisional step and bonding exclusively
to enamel. Disadvantages are the meticulous and thorough manufacturing of the labora-
tory step, increased risk of fracture during the various steps of the process (laboratory,
try-in and cementation) due to thinness of the veneer, critical cementation process and
thoughtful maintenance therapies, concerning the maintenance of the aesthetic result,
considering that prepless veneers do not involve the areas of dynamic visibility, which will
become visibly present with the natural darkening of the dental substrate.
CONVENTIONAL OR WITH PREPARATION

Preparations for ceramic veneers have undergone many changes and advances. The
preparation shape can be influenced by tooth shape, location and orientation in the arch,
tooth anatomy, occlusal function, mechanical forces, quantity and quality of the remaining
tooth structure and anticipated final restorative dimension.21,22,41,42,11 By using these clinical
considerations, modifications in the preparation shapes may be varied and find a multitude
of shapes, being guided by the pre-existing defect or depending on the anticipated dimen-
sion of the final restoration and the substrate shade.
Indications for ceramic veneers with full preparation are:
• discolored teeth;
• restored teeth;
• proclined, rotated or misplaced teeth;
• large diastemata and involved walls converging to incisal; and
• occlusal restorations for the reestablishment of the vertical dimension of occlusion.
Contraindications include:
• extensively restored teeth;
• presence of large amounts of dentin in the post-preparation substrate; and
• Severely discolored single tooth (more than four tones).
When the preparation is necessary, the depth of wear has a direct influence on the
establishment of the desired ceramic veneer shade after cementation. A 0.9 mm wear of
the substrate is capable of promoting a change from an A4 shade to an A1 shade (Vita
Classical® shade guide, Vita, Germany); a reduction of 0.5 mm creates a shift from an A4
to an A2; a reduction of 0.3 mm does not produce any color change; rather, final color
adjustments with resin cement are necessary.22
245
Figure 8.
Figure 8. A 0.9 mm reduction of the substrate is able to promote change in color from an A4 to an A1 (Vita Classical® shade guide, Vita, Germany); an reduction of 0.5 mm creates change from an A4
to an A2; and an of 0.3 mm reduction does not produce any color change
Despite a multitude of preparation methods, always guided by the pre-existing de-

fect or by the restorative morphology planned the protocol for ceramic veneers with spe-
cific preparations should didactically follow the following.
1. Control of reduction with silicone guides. The preparation design for ceramic vene-
ers should allow for an optimal marginal adaptation of the definitive restoration and
maximally resembling the ideal tooth morphology. Therefore, a diagnostic wax-up
should be utilized as a reference for tooth reduction. Silicone guides, fabricated over
the wax-up, provide simple and indispensable tools for control and in reduction of
enamel.21,22 Two guides should be fabricated: a vertical guide (sectioned in the buc-
colingual direction) for reduction control in cervicoincisal direction; and a horizontal
guide for the mesiodistal reduction control. With teeth darkened by endodontic treat-
ments in which the labial surface is intact and the rehabilitation of which will maintain
the natural morphology, the silicone guide may be fabricated directly within the mouth
and prior to preparation.2,3 (Fig. 9)
246
Figure 9g.
Figure 9. PVS impression material (Elite HD, Zhermack, Italy) for manufacturing the preparation guides (a); Diagnostic wax-up (b); obtaining two guides for the manufacture of horizontal and vertical
reduction guides (c);cutting on the buccal surface of the medial portion (d) for building the vertical reduction guide (e); conference of the reduction vertical guide on the diagnostic wax-up (f) and
horizontal reduction guide obtained with three slices carried out in the cervical, middle and incisal thirds (g).
247
2. Peripheral delimitations of the preparation with spherical diamond burs surrounding
the entire labial surface of the tooth without disruption of the proximal contact and
without subgingival extension (Fig. 10e). New diamond burs, a kit of handpieces
(high speed, low speed, micromotor and a multiplier) which lend stability to the pre-
paration and polishing process, without variation in the axis of rotation of the diamond
tips, aluminum oxide discs and finishing and polishing rubbers are fundamental for a
preparation without risks and a smooth and regular surface. (Fig. 10f -h)
3. Preparation of vestibular grooves in the vertical direction with rounded-ended conical
diamond burs (FG 2135, KG Sorensen®, Brazil), respecting the axial inclinations
(cervical, middle and incisal) to preserve the convergence of the buccal surface. (Fig.
10i) The depth of each groove is defined according to each case and based on the
diagnostic wax-up. Another modality of vestibular groove preparation is to perform a
central groove respecting the same concepts of axial inclinations, for posterior wear
of only one of the sides until the limit of the contour peripherically. (Fig. 10j) In this
way, one can check the amount of wear with a millimeter probe by comparing the
prepared side with the intact. At this point, it is essential to have knowledge about
the thickness of the labial enamel of a natural tooth, so that the completion of the
preparation is performed, having also the preservation of enamel as a guide whene-
ver possible.14 (Fig. 11)
4. Joining the labial grooves with a conical diamond bur, the larger diameter to prevent
deepening of the guide grooves and forming an uneven surface. (Fig. 10k)
5. Performing the proximal preparation with a diamond bur of smaller diameter (Fig. 10l).
The protection of the adjacent teeth with metal matrix is imperative. The proximal
extension of the preparation is directly associated with the static and dynamic area
of visibility and preexisting restorations. The observation of the preparation in a static
way, merely by labial, gives a false impression that all visible areas of the substrate
were included in the preparation. Thus, the dynamic view of the preparation laterally
enables an actual verification on whether or not to proximally extend the preparation.
(Fig. 10m-o) This stage is characterized as one of the most conflicting points with the
pragmatism of conventional preparations for fixed prosthesis, performing reduction
to enable insertion axes and elimination of retentions. It is essential to understand
the fact that the majority of cases of ceramic veneers with or without preparation,
presents a passive fit in the labial-palatal direction, and the supposed interproximal
retentions are overlooked when veneers “fit in” without resistance. In this way, it is
possible to carry out more conservative interproximal preparations, restricted mainly
to the cervical region even if retentions exist when viewed pragmatically in an inciso-
cervical sense.
6. The incisal reduction of preparation. Incisal terminations, as highlighted in Figure 10p,
may be defined as: 0°, straight, 45º and chamfer.
The traditional clinical recommendations are: 0º for ceramic fragments; straight and
45º for conventional or prepless veneers (Fig. 10p); and chamfer for specific con-
ventional veneers, such as those with a very thin incisal thickness, need for rebuil-
ding from 1.0 mm to 2.0 mm volume of restorative material in the incisal, presence
248
of structurally compromised incisal enamel and individuals with incisal parafunction
subject to functional stress.
The 0º termination is critical because of the difficulty in the cementation process.
Furthermore, it may result in an aesthetic problem due to the fact that the preparation
finishes in the most translucent area of the tooth. This is indicated in cases of subs-
trates with a desired value without chromatic alteration in the incisal region.
The chamfer termination, although the preparation is slightly extended to the lingual
surface increasing the total surface of enamel for bonding, at the same time also cre-
ates the correct path for insertion during the try-in and cementation.15-17 The authors
do not advocate performing this termination because the biological cost is higher.
Creation of an insertion path facilitates the cementation step, however promotes a
higher volume of wear, particularly in the proximal regions to eliminate retentions.
Hence, straight-type incisal terminations are preferably chosen when reduction is ne-
cessary, because it advocates a passive fit in the the labial-palatal direction without
a deliberate insertion axis, greater preservation of tooth structure and lends absolute
confidence in the bonding mechanisms.
7. Checking the incisal reduction. Positioning of the vertical guide to check the incisal
space should be at least 1.5 mm.2,3,18,30,32,20 The incisal involvement offers many
advantages,30 above all by the possibility of incorporating incisal characterizations
such as translucency, evidence of the spindles and of the opacity of the halo to the
restorations, mimicking its naturality. (Fig. 10q)
8. Preparation of the subgingival cervical margin and initial finishing of the preparation
in indicated situations with rounded-ended diamond burs (F or FF series, KG So-
rensen®, Brazil) using a multiplier. It is worth to emphasize the importance of gingival
tissue protection during preparation, in order to prevent post-traumatic gingival re-
cession, especially in thin marginal tissue. (Fig. 10r)
9. Finishing and polishing of the preparation with abrasive silicone rubbers (Composite
Technique Kit®, Shofu, Japan) with decreasing granulation. Every angle and corner
should be uniform, with rounded lines, to improve the adaptation of the resin cement
and laboratory build-up. In addition, healthy tooth structure must be removed when
the contour requires extension to a point beyond or within the functional stops pre-
viously indicated.42
249
Figure 10j.
Figure 10. Photography at rest showing an ideal condition (a); harmonic smile presenting only the 11 tooth with tooth darkening caused by an unsuccessful endodontic treatment (b); intraoral aspect of
tooth 11 (c); shade selection (d); peripheral delimitation with spherical diamond point (e); Ceramic Veneers burs set - Dentistry ABO Goiás (KG®, Brazil) (f); preparation performed with high speed turbine
with LED lighting (W&H®, Austria) (g); contra-angle with LED light and multiplier (W&H®, Austria) (h); preparation of the orientation grooves with a rounded-ended conical diamond point (i); the orientation
grooves must follow the three inclinations of the tooth. Note that the natural teeth have three slopes: 1- cervical third, 2- middle third and 3- incisal third (j); joining of the orientation grooves (k); proximal
involvement by the presence of an extensive renovation on the mesial aspect (l); Notice that when the proximal reduction is insufficient, it can be seen clearly in the dynamic view the bonding line of the
veneer with the darkened substrate (m); thus, the ideal would be to extend the preparation more proximal, and thus the dynamic view area would be appropriate (n); vision of dynamic visibility of the
preparation; the incisal terminations described in the literature are 0 °, straight, 45 and bevel (p); note the appearance of the straight termination (q); subgingival extension prepared with fine diamond
burs positioned in the multiplier (r); after polishing of the preparation, the previously fabricated wear guides are positioned on the darkened tooth. In this clinical case the wax-up was not needed since
the shape of the tooth was adequate; horizontal guide of the incisal third (s);horizontal guide of the middle third (t); horizontal guide of the cervical third (u); vertical guide (v); after approval of preparation,
the impression and confection of the feldspathic porcelain is carried out. Note the detail of the smile after cementation (w) and intraoral view of the finished case (x-z). Responsible ceramist: Leonardo
Bocabella.
250
0o Straigth 45o Chamfer

Figure 10p.
Figure 10q. Figure 10r.
Figure 10s. Figure 10t. Figure 10u.
251
Figure 10v. Figure 10w.
Figure 10x. Figure 10z.
Incisal Third 1.0 - 1.3 mm
Middle Third 0.8 mm
Cervical Third 0.4 - 0.6 mm
Figure 11.
Figure 11. Note that the average thickness of enamel at the incisal third of a central incisor is 1.0 mm to 1.3 mm; in the middle third, 0.8 mm; and the cervical third, 0.4 mm.
252
Degree of darkening
Tooth darkening, or above all in an isolated tooth, represents a major challenge for
the restoration of optical characteristics with the naturalness of adjacent teeth as a refe-
rence. In this case, the alternatives for establishing a good result are performing a more
invasive preparation (Fig. 12), using opacifiers before the impression taking, the selection
of a less translucent ceramic, with masking capability of the darkened substrate, the use
of more opaque and/or higher value resin cements, and also the combined use of the
afforementioned alternatives.1,38
Conceptually, the rehabilitation of darker teeth requires greater preparation depth;
however, the challenge of conservatism is to remove a minimal amount of tooth structu-
re, and at the same time avoid the risk of inadequate tooth reduction for the proposed
ceramic restoration. Until recently, severely discolored teeth represented a situation of
contraindication for veneers. However, the improvement of ceramic systems and the as-
sociation of new ingots with a higher control of light transmission have enabled performing
more conservative techniques as well as build-ups on discolored substrates with an in-
creasingly more natural result.9
Wherever possible, the use of ceramic veneers on discolored substrates need to
provide a balance between its capacity to mask the substrate and the final aesthetic result.
Increased thickness of the restoration and the use of a lower translucency ceramic colla-
borate with the masking. However, increased thickness necessarily means more invasive
tooth preparation, which reduces the amount of enamel available for bonding procedures,
thus decreasing the clinical success expected for the porcelain veneer.
Currently, the dental market makes available a range of ceramic systems with diffe-
rent degrees of translucency, suitable for the manufacture of ceramic veneers. Excessively
opaque ceramics such as E-max®, MO (medium opacity) and HO (high opacity) (Ivoclar
Vivadent, Liechtenstein) are uncapable of simulating the optical behavior of tooth enamel,
which is characterized by its translucency, lending to restorations an artificial, unsightly
appearance.
Hilgert,24 studied the ability of ceramic veneers to mask discolored backgrounds in
an aesthetically acceptable manner with decreased biological cost, concluded as follows:
(1) for non discolored substrates, such as A1 (Vita Classical® shade guide, Vita, Germany),
high translucency ceramic systems with a thin thickness may be reliably utilized (0.4 mm)
- Empress Aesthetic® HT (Ivoclar Vivadent, Liechtenstein) and E-max® HT (Ivoclar Viva-
dent, Liechtenstein); (2) slightly discolored substrates (A3,5 VitaClassical® shade guide,
Vita, Germany) were masked acceptably with a conservative preparation (0.4 mm reduc-
tion), if associated with low translucency ceramics (EmpressCAD® LT, Ivoclar Vivadent,
Liechtenstein); and (3) severely discolored substrates (C4, VitaClassical® shade guide,
Vita, Germany) were restored acceptably by merely executing an invasive preparation (1.0
mm) and low translucency ceramics (EmpressCAD® LT, Ivoclar Vivadent, Liechtenstein).
(Fig. 13a-b)
253
Figure 12a. Figure 12d. Figure 12e.
Figure 12f. Figure 12i. Figure 12j.
Figure 12. Male patient unsatisfied with the smile (a); dentolabial view demonstrating changed gingival contour, presence of composite resin veneers and darkening of the tooth #11 (b); intraoral detail
of the initial condition (c-d); after periodontal surgery a new diagnostic wax-up was performed focusing in the shape of the dental elements (e). The reduction guides and guide for preparation of the
provisional were fabricated on the wax-up. Notice the vertical guide positioned on the dental element yet without reduction. Important information prior to reduction, given that there will be a small
increase in volume and therefore, the wear shall not be too much invasive (f); peripheral delimitation with spherical diamond point (g); preparation of the orientation grooves (h); joining of the orientation
grooves (i); preparation ended with subgingival extension of the tooth #11. Notice that the preparation of the tooth #11 is deeper because of the degree of darkening of the preparation of 21, which
appears clear (j); evaluation of the preparation with the cervical guide (k-l); ceramic veneers of the teeth 15 and 25 cemented (m); Final smile (n); face in complete harmony (o); and naturalness (p).
254
Figure 12o.
255
Figure 12p.
256
Figure 13a.
Figure 13b.
Figure 13. Ceramic veneers of the same thickness but with different opacities (left side Emax HT®, Ivoclar Vivadent, Liechtenstein; and right side Emax LT®, Ivoclar Vivadent, Liechtenstein) on black
background (a) and on white background(b).
257
The good color mimicry associated with conservative preparation shows relative biolo-
gical cost/high aesthetic result, and there is no reason to choose for deeper preparations in
cases where there is no need for masking the darkened background. Therefore, definitively,
the establishment of a tooth bleaching protocol becomes fundamental, as described in sec-
tion 5.3, to increase the value of the discolored teeth, to promote the desired conservatism,
to homogenize the color of all substrates, to minimize the interference of the resin cement
color in the process of determining the final result and create opportunities using thinner
ceramic veneers.
Proclination of the teeth

Proclined teeth deserve a careful evaluation as to whether or not to reduce, and
the mock-up turns into an excellent device towards design planning. Teeth with a slight
proclination require the positioning of the mock-up to accurately determine the location of
the reduction and allow for maximum preservation of dental structure. Small perforations in
the mock-up reveal the exact location where the reduction should be carried out. Dental
crowding is usually associated with proclination and therefore needs that the tooth reduc-
tion which was planned in the diagnostic wax-up and/or mock-up until the acrylic guide
provided by the ceramist (Fig. 14a-d).
Figure 14. Initial smile revealing diastemas and presence of tooth 13 and rotated and buccally inclined, and the tooth 22 buccally inclined (a);intraoral detail of the buccally inclined teeth (b); observe the
preparations confectioned in the teeth #13 and #22 (c); final smile (d)
258
The use of an acrylic guide made by the ceramist, as shown in Figure 15, is also an
excellent choice for guiding the tooth preparation. Remember that both the mock-up as
well as the acrylic guide are tools used from the final sight of the restorative dimension and
are intended to minimize dental wear.
The mock-up is neglected in cases of generalized proclination, it is impossible to ins-
tall it in order to help the diagnostics and predict the aesthetic results without a previously
prepared wax-up on a plaster model, removing unwanted morphological characteristics
due to the establishment of the new rehabilitation. Therefore, an aesthetic rehabilitation
planning performed digitally is a tool of great interest for the visual presentation of the case
to the patient. Categorically, the abolition of the use of a mock-up is solely acceptable in
this situation.
Figure 15. Initial smile (a); Initial intraoral aspect (b); preparation of the acrylic guide on the stone model to guide the reduction (c);positioning of the guide on the mouth (d); reduction with a diamond point
with the acrylic guide positioned (e); appearance after reduction (f); final result after cementation of ceramic veneers of from #13 to #23 (g-h); and final smile (i).
259
Presence of restorations
The presence of Class III, IV and V composite restorations in teeth undergoing cera-
mic veneers with preparation is common. According to Dunne & Millar,12 their maintenance
in the preparation and the cementation of ceramic veneers can provoke several problems,
such as microleakage, caries recurrence and fractures.
However, there exist some situations where it is possible to maintain the composite
restorations. Thus, it becomes necessary to find reliable clinical parameters that indicate
the real possibility of maintaining these restorations. The maintenance or replacement of
the composites depends on the location, extent and degree of aesthetic commitment of
the remaining substrate.35
The interproximal extension comprises conventional or slice preparations. In the con-
ventional preparation, the reduction is carried out in the interproximal area and prior to the
contact point. This condition is indicated in teeth with presence of small and medium-si-
zed proximal restorations. Slice preparations continue across the interproximal area and
above the lingual surface, being indicated in teeth with the presence of large proximal
restorations, diastema closure, discolored teeth, and in situations that require a change in
the tooth width. (Fig. 16)
According to Baratieri et al. (2002),2 the preparation of the proximal surface should
be carried out so as not to allow the discolored tooth structure to be visible after cementa-
tion of the veneer. It is therefore very important to know the concept of static and dynamic
areas of visibility. The static area consists of observing the patient and consequently the
tooth to be veneerd frontally. Seen in this manner, the preparation or the restoration may
always seem appropriate; however, when the observer searches the area of dynamic
visibility, he realizes that the preparation is inadequate and that the proximal extension was
insufficient, leaving a wide visible dark area on this surface.
Whenever possible, the proximal contacts should be maintained in a natural tooth
because they represent an anatomical feature which is very difficult to reproduce, prevent
the movement of the teeth in the arch during the fabrication of the porcelain veneer, es-
pecially when provisional veneers are not used, facilitating the adjustment of the veneers,
turning the bonding and finishing procedures simpler, as well as facilitating the control of
bacterial plaque.2
In situations of complete involvement of both proximal surfaces of the dental ele-
ment, straight or 45º terminations are recommended in the incisal portion, which favors
the insertion of the veneer, being that the chamfer termination demands a greater volume
of proximal reduction to enable the insertion of the piece in the incisocervical direction (Fig.
17). Therefore, the carrying out of full-crown preparations is indicated.
Class V restorations should be considered as filling cores, instead of removing them
entirely, because this would generate a considerable biological cost, whether it be by re-
moving the tooth structure for the proper removal of the old restoration, or by removal of
the tooth structure for preparation and elimination of peripheral retentions, especially along
the upper cavity wall. What is imperative is the replacement of all of the old Class III and V
restorations, by applying the acknowledged etching and bonding principles for composite
restorations, inserting of shades (dentin) similar to the substrate and maintaining the mar-
260
Conventional Slice
Figure 16. Teeth with the presence of small and medium-sized proximal restorations, require conventional interproximal area, in which the reduction is carried out in the interproximal area and anterior to
the contact point (A). In teeth with large restorations, the interproximal preparation should be in the shape of a slice, whose wear involves the interproximal area and continues on the lingual surface with
butt joint (B).
Figure 17. Teeth with complete involvement of both proximal surfaces and straight incisal termination favor the insertion of the veneer (A); and teeth with complete involvement of both proximal surfaces
and finishing beveled require a greater volume of proximal reduction, to allow for the insertion of the piece in an incisocervical sense (B).
gins always on the tooth, suitable for cementation of the ceramic on the tooth structure. Class IV restorations are always
completely removed, as the ceramic will restore the lost portion of the tooth structure with impressive biomimetics and
desired naturalness of the result.
Diastemata
The major concern in diastemata rehabilitation is the formation of black triangles and the inadequate manipulation of
the gingival tissue. Thus, it is essential that the proper understanding of the formation of the black triangle is directly linked
to the positioning of the contact point and that the misleading tooth preparation for installation of the ceramic veneer dis-
courages the emergence profile.30 (Fig. 18)
Gingival embrasures are ideally filled by the interdental papillae, but their presence or absence is directly correlated to
the distance between the contact point and the bone crest.15,30
According to Tarnow,40 when there exists a distance greater than 5 mm between the bone ridge and the point of
contact there will be a formation of the black triangle. Less than or equal to 5 mm between the contact point and the bone
crest allows the formation of interdental papillae, hence, absence of the black triangle.
261
Figure 18.
Figure 18. Schematic drawing of the diastema between the central incisors with mesial walls converging to incisal (A); ceramic veneers cemented without preparation, which prevents the formation of an
appropriate emergence profile and inadequate manipulation of the gingival tissue (B); ceramic veneers cemented with invasion of biological distances, artificial emergence profile and closure of the black
triangle in an inadequate manner (C); and ceramic veneers cemented after subgingival preparation of the mesial surfaces, which enables the subgingival seating and therefore the creation of a contact
point favorable for soft tissue manipulation and formation of the papilla.
262
The diastemata may be small and generalized, which allows for the performance of ceramic veneers without prepa-
ration (Fig. 3 and 4). In extensive diastemata, principally in central incisors, ceramic veneers must be performed with the
objective of establishing a point of contact more cervical, establishing the conditions for the manipulation of gingival tissue
and the formation of interdental papillae with triangular morphology. (Fig. 19) For this purpose the carrying out of a subgin-
gival preparation is essential, which favors the ceramics fabrication, with respect to the precepts of the natural emergence
profile, displacing the surface contact to the nearest region cervically26,27 the naturalness of the aesthetic result of the ce-
mented ceramic veneers. What is imperative with such a subgingival preparation in areas of extensive diastemata where
increased biological dimensions, as well as increased tissue volume are allowed and keratinized tissue present, which
favors the subsequent subgingival cementation without loss of the naturalness or development of inflammatory processes.
Further, this condition gives opportunity for tissue manipulation and proper conditioning, transforming the linear aspect of
the papillae between the diastemata within morphologically triangular and the natural looking papillae.
The evolution of techniques and materials related to ceramic veneers modified the dogmatic conventional fixed pros-
thesis preparations promoting convergence between involved walls and establishing the insertion axis through preparations
or selective reduction whose conservative aim for maintaining a maximum of tooth structure, especially enamel, and the
promotion of passive fit in the labial-palatal direction without the formation of mechanical stresses on the ceramics and
naturalness in the result from the use of considerably translucent ceramics, with optical and chromatic features that mimic
the missing or replaced dental structure.
Figure 19b.
Figure 19. Initial face (a); smile demonstrating the presence of defective composite resins, and diastemata (b); intraoral view reveals the presence of altered gingival contour and interincisal diastemata
(c); after removal of the defective composite restorations, the subgingival preparation was carried out (d); observe detail from the model of the mesial surfaces and subgingival extension favoring the
emergency profile (e); ceramic veneers cemented revealing favorable conditions for manipulation of the gingival tissue (f-g); final facial aspect (h-i).
263
Figure 19h.
264
Figure 19i.
265
1. Almeida e Silva JS, Rolla JN, Edelhoff D, Araújo E, Baratieri LN. All-ceramic crowns and extended veneers in anterior dentition: a
REFERENCES
case report with critical discussion. Am J Esthet Dent. 2011;1:60-81.
2. Baratieri LN, et al. Odontologia restauradora: fundamentos e possibilidades. São Paulo: Santos; 2002.
3. Baratieri LN, Guimarães J. Laminados cerâmicos. In: Baratieri LN. Soluções clínicas: fundamentos e técnicas. Florianópolis:
Ponto; 2008. p. 214-71.
4. Black GV. Management of enamel margins. Dent Cosmos. 1891;33:85-100.
5. Burke FJT. Survival rates for porcelain veneers with special reference to the effect of preparation in dentin: a literature review. J
Esthet Restor Dent. 2012;24(4):257-65.
6. Calamia JR. Etched porcelain veneers: the current state of the art. Quintessence Int. 1985;16(1):5-12.
7. Cardoso PC, Decurcio RA, Almeida e Silva JS, Perillo MV, Baratieri LN. Noninvasive porcelain veneers: a comprehensive aesthetic
approach. Am J Esthet Dent. 2012;2:238-54.
8. Christensen GJ. Longevity versus aesthetics: the great restorative debate. J Am Dent Assoc. 2007;138(7):1013-5.
9. Christensen GJ. The advantages of minimally invasive dentistry. J Am Dent Assoc. 2005;136(11):1563-5.
10. De Munck J, Van Landuyt K, Peumans M, Poitevin A, Lambrechts P, Braem M, et al. A Critical review of the durability of adhesion
to tooth tissue: methods and results. J Dent Res. 2005;84(2):118-32.
11. Dietschi D, Spreafico R. Adhesive metal-free restorations: current concepts for the aesthetic treatment of posterior teeth. Chicago:
Quintessence; 1999.
12. Dunne SM, Millar BJ. A longitudinal study of the clinical performance of porcelain veneers. Br Dent J. 1993;175(9):317-21.
13. Faunce FR, Myers DR. Veneer restoration of permanent incisors. J Am Dent Assoc. 1976;93:790-2.
14. Ferrari M, Patroni S, Balleri P. Measurement of enamel thickness in relation to reduction for etched veneers. Int J Periodontics
Restorative Dent. 1992;12(5):407-13.
15. Fradeani M. Aesthetic analysis: a systematic approach to prosthetic treatment. Chicago: Quintessence; 2004.
16. Fradeani M. Six-year follow-up with Empress veneers. Int J Periodontics Restorative Dent. 1998;18:216-25. Fradeani M, Re-
demagni M, Corrado M. Porcelain laminate veneers: 6 to 12 years clinical evaluation: a retrospective study. Int J Periodontics
Restorative Dent. 2005;25:9-17.
17. Freire A, Archegas LRP. Porcelain veneer veneer on a highly discoloured tooth: a case report. J Can Dent Assoc. 2010;76:a126.
18. Friedman MJ. A 15-year review of porcelain veneer failure: a clinician’s observations. Compend Contin Educ Dent. 1998;19:625-
8.
19. Gürel G. Porcelain laminate veneers: minimal tooth preparation by design. Dent Clin North Am. 2007;51(2):419-31, ix.
20. Gürel G. Predictable, precise and repeatable tooth preparation for porcelain veneers: practical procedures & aesthetic dentistry:
PPAD. 2003;15(1):17-24.
21. Gurel G. The science and art of porcelain veneers. Berlin: Quintessence; 2003.
22. Hilgert LA, Lopes GC, Araújo E, Baratieri LN. Adhesive procedures in daily practice: essential aspects. Compend Contin Educ
Dent. 2008;29(4):208-15; quiz 216, 218.
23. Hilgert, LA. Influência da coloração do substrato, espessura e translucidez da cerâmica na cor de facetas laminadas produzidas
com o sistema CEREC inLab [tese]. Florianópolis, UFSC; 2009.
24. Horn HR. Porcelain laminate veneers bonded to etched enamel. Dent Clin North Am. 1983;27(4):671-84.
25. Kelly JR, Benetti P. Ceramic materials in dentistry: historical evolution and current practice. Aust Dent J. 2011;56(1):84-96.
26. Kelly JR. Dental ceramics: what is this stuff anyway? J Am Dent Assoc. 2008;139:4S-7S.
27. Layton DM, Clarke M, Walton TR. A systematic review and meta-analysis of the survival of feldspathic porcelain veneers over 5
and 10 years. Int J Prosthodont. 2012;25(6):590-6.
28. Lin T-M, Liu P-R, Ramp LC, Essig ME, Givan DA, Pan Y-H. Fracture resistance and marginal discrepancy of porcelain veneer
veneers influenced by preparation design and restorative material in vitro. J Dent. 2012;40(3):202-9.
29. Magne P, Belser U. Estética dental natural: restaurações adesivas de porcelana na dentição anterior: uma abordagem biomimé-
tica. São Paulo: Santos; 2003.
30. Magne P, Hanna J, Magne M. The case for moderate “guided prep” indirect porcelain veneers in the anterior dentition: the
pendulum of porcelain veneer preparations: from almost no-prep to over-prep to no-prep. Eur J Esthet Dent. 2013;8(3):376-88.
31. Magne P. et al. Clinical performance of novel-design porcelain veneers for the recovery of coronal volume and length. Int J Perio-
dontics Restorative Dent. 2000;20:440-57.
32. Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental restorations over 14 years. Part II: effect of thickness of Dicor
material and design of tooth preparation. J Prosthet Dent. 1999;81(6):662-7.
33. Meyer Filho A, Vieira LCC, Baratieri LN, Lopes GC. Porcelain veneers as an alternative for the aesthetic treatment of stained ante-
rior teeth: clinical report. Quintessence Int. 2005:191-6.
34. Peumans M, De Munck J, Fieuws S, Lambrechts P, Vanherle G, Van Meerbeek B. A prospective ten-year clinical trial of porcelain
veneers. J Adhes Dent. 2004;6(1):65-76.
35. Raigrodski AJ. All-ceramic full-coverage restorations: concepts and guidelines for material selection. Pract Proced Aesthet Dent.
2005;17:249-56; quiz 258.
36. Rosenblum MA, Schulman A. A review of all-ceramic restorations. J Am Dent Assoc. 1997;128(3):297-307.
37. Sadowsky SJ. An overview of treatment considerations for aesthetic restorations: A review of the literature. J Prosthet Dent.
2006;96(6):433-42.
38. Calamia JR, Simonsen RJ. Tensile bond strengths of etched porcelain. J Dent Res. 1983;62:297, Abstract 1099.
39. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or
absence of the interproximal dental papilla. J Periodontol. 1992;63(12):995-6.
40. Terrey DA, Geller W. Odontologia estética e restauradora: seleção de materiais e técnicas. Chicago: Quintessence; 2014.
41. Terry DA. Natural aesthetic with composite resin. Mahwah, NJ: Montage Media; 2004.
42. White JM, Eakle WS. Rationale and treatment approach in minimally invasive dentistry. J Am Dent Assoc. 2000;131:13S-9S.
266
267
chapter 6.2
ceramic fragments
Victor Clavijo | Andréa Melo | Cristiano Soares
Currently, dental repairs that aim to redesign the beauty of the smile are routine in
INTRODUCTION
most dental clinics. In contrast, the repairing treatment may have undesirable results if not
properly indicated and planned. The expectation of the patient sometimes hinders the
development of aesthetic cases, due to numerous clinical and biological limitations, which
must be respected and properly explained. Knowing the articular disorders, as well as
the masticatory forces, dietary habits and parafunctions is critical to the development of
diagnosis and the correct indication of ceramic restorations.
The longevity of conventional ceramic veneers comes from the possibility of bon-
ding to the tooth,1 as well as the different characteristics of ceramic materials that are
already largely known, namely: chemical resistance; biocompatibility; thermal expansion
coefficient similar to that of tooth structure; high resistance to compression and abrasion;
adequate toughness, excellent reproduction of the optical properties of the tooth structu-
re; radiopacity; bonding to luting agent and tooth substrate; and color stability according
to works with clinical follow-up of up to 21 years.2-7 The maintenance of enamel is vital to
the durability of ceramic veneers, so, the greater the amount of remaining enamel in the
dental structure, the more favorable is the cementation and the smaller the deflection of
tooth structure when subjected to masticatory forces, which prolongs the durability of the
ceramic. So ceramic veneers are devoted as a safe and feasible alternative for restora-
tions when cemented on enamel.
The clinical success of conventional veneers, concurrently with the development of
ceramic materials and the consolidation of the adhesion principles,2 combined with the
minimally invasive philosophy culminated in the development of many types of adhesive
restorations for reconstruction of the smile.
Today the possibility of ceramic restorations to cover partially only the tooth surface
stands out. Such restorations are called ceramic fragments, and the presentation of a
clinical protocol for its implementation is the purpose of this chapter.
The cementation a ceramic restoration of the fragment type may be compared with
LITERATURE
REVIEW
bonding techniques involving tooth fragments after trauma. These techniques are under
discussion since 1964, when Chosack & Eigdelman8 described an approach on frag-
ment collage of the proper fractured dental element on a central incisor after injury. Since
then, new studies with different techniques on the collage of fragments after tooth fractu-
res have been reported. In 1990, Baratieri et al. indicated bonding of the tooth fragment
itself as a treatment of choice when viable with satisfactory aesthetic results; maintenance
of the anterior guide in enamel; and emotional and social recovery of the patient. The pre-
paration of partial ceramic restorations cemented on enamel emerged following the same
philosophy of bonding fragment on tooth remaining after injury without its reduction.9
270
Kyrillos & Moreira presented a case report of partial restorations made of ceramic
fragments and stressed the importance of thorough multidisciplinary planning for their
longevity.10
The clinical step-by-step of the ceramic fragment technique on the incisal edge with
minimal tooth reduction was described by Clavijo & cols.11 Following the philosophy of
minimum reduction, the paper reports another case with multiple fragments for closure
of diastemata, through partial restorations in the mesial and distal aspects without any
tooth preparation. In 2011, the same authors described the ceramic fragments technique
without tooth reduction.12 In the same period, Gresnigt & cols. reported a case with partial
restorations associated with veneers with full coverage of the labial surface. At the time,
the authors emphasized that the bonding, finishing and polishing steps are fundamental to
the performance of the restoration.13
Horvath & cols. described another case report that used the technique of thin partial
ceramics as a solution for class IV restoration of a maxillary incisor.14 The aim was to des-
cribe a minimally invasive method for indirect restorations. Tooth preparation was limited
only to the removal of the old resin restoration. Thus, the margins of the ceramic remained
in the middle third region. The rationale given by the author for using ceramics was greater
color stability, less accumulation of plaque and higher mechanical strength.
Antonio Signore & cols. described a technique for closing diastemata between cen-
tral incisors using fragments without any tooth preparation, taking into account that the
shape of both incisors made possible the insertion of the ceramic fragments. The authors
underlined that in cases where no indication is given for tooth preparation are restricted
and must be considered with caution.15
Andrade & cols. reported a follow-up, after a mean of five years, of six clinical ca-
ses. They were all fabricated with minimally invasive ceramic restorations and, after ce-
16
mentation, finishing and polishing procedures, they exhibited a ceramic-cement-enamel

interface as usual. On that occasion the authors denominated this region of continuous
adhesive area and concluded that the evaluation of the longevity of these interfaces throu-
gh the study of micrographs is effective.
Ceramic fragments are ceramic restorations that cover partially one or more surfaces
WHAT ARE
CERAMIC
FRAGMENTS?
of the tooth.
271
The ideal of ceramic fragment type of restorations is to be a minimally invasive pro-
FOR INDICATION OF
CERAMIC FRAGMENTS
DETERMINING FACTORS
cedure, which avoids unnecessary wear of the healthy tooth structure. These restorations,
however, require higher degree of accuracy of the professional in the indication of the
technique and their fabrication.
There are four determining factors in choosing the method:
1. The shade of the tooth to be restored must be the desired, since fragments by their
minimum thickness, are not able to block remnants that require color change.
2. By observing the space for the restoration one should only fabricate the fragments
for cases in which replacement or augmentation of volume of tooth structure is re-
quired.
3. The insertion axis of the fragments must be evaluated to check whether or not remo-
val in small undercuts is required.
4. The laboratory must master the manufacturing technique.
These restorations are indicated in situations where the tooth position allows to ad-
d-up material, because even if minimal reduction is necessary, this should be started and
finished in enamel. The maximum amount of viable enamel is thereby maintained in order
to large deformation of the tooth structure not take place when subjected to masticatory
forces.17 Similarly, optimization of adhesion occurs, since ceramic fragments are extremely
fragile, without mechanical retentions and absence of resilience, depending therefore, of
the adhesive and mechanical properties of healthy tooth enamel for increased longevity.
So, they are indicated in situations as increasing of the incisal edge, increasing of the labial
volume, closing or reducing diastemas, incisal fractures, restoration of the canine guidan-
ce, non-carious cervical lesions and even partial occlusal restorations for reestablishment
of the occlusion after erosive or abrasive process with loss of tooth structure. In Table 1 it
can be observed the main clinical indications, teeth usually involved and advantages when
the ceramic fragment is a treatment option in the corresponding indications.
Table 1. Indications, involved tooth and clinical advantages of ceramic fragments.

INDICATIONS . TOOTH INVOLVED . CLINICAL BENEFITS OF CERAMIC FRAGMENT
Anterior guidance recovery Maxillary and/or mandibular incisors Greater stability of the material due to the potential
. . . mechanical resistance to wear
Canine guidance recovery Canines Longevity
Occlusal enamel recovery due to Premolars and molars Long term stability of the occlusion in restoration
mechanical wear or erosion . . .
Cervical lesions - Class V Premolars and molars, possibly canines Ease of adherence of the gingival tissue due to increased
. . smoothness of restoration
Diastema closure Anterior and posterior Prevents tooth grinding required in conventional veneers
. teeth . which cover the entire labial surface and have cervical
. . termination
Class IV restoration Central and lateral incisors Color stability, ease of adjustments, less time of in-office
. . service
Repair in ceramic restorations Any restoration that has suffered minor fractures Prevents removal of adapted restorations to prevent tooth
and have well adapted margins grinding and allow greater biological conservation
272
When there is no possibility of the insertion or there is inability to achieve the desired
WHEN ARE
THE CERAMIC
FRAGMENTS
CONTRAINDICATED?
shape just by adding restorative material, fragments are contraindicated. In these two clini-
cal situations, increased wear of tooth structure to redesign the smile becomes necessary.
Additionally, in cases where there are severe occlusal dysfunctions, with loss of sound
tooth structure, tooth fragments must not be used for restoration of the lost anatomy.
Rehabilitation procedures are necessary in those cases involving other specialties, for
the purpose of accurate diagnosis and treatment of occlusal disorders. Table 2 illustrates
the main clinical situations when the prognosis for implementing ceramic fragments is not
favorable.
Table 2. Unfavorable prognostic for executing ceramic fragments.

CLINICAL SITUATION ABSOLUTE CONTRAINDICATION RELATIVE CONTRAINDICATION
Darkened substrate X
Absence of insertion axis X
Bonding area partially in dentin X
Untreated occlusal dysfunctions X
Since this is a very sensitive technique, possible casualties may occur during the
CLINICAL
DIFFICULTIES
process. Table 3 describes the most common clinical intricacies during the manufacture
of restorations such as ceramic fragments and their reasons.
Table 3. Clinical complexities for making ceramic fragments.

CLINICAL DIFFICULTY REASON
Demarcate small areas of grinding Selective grinding should be performed so that the restoration is
. inserted passively
Absence of contact point Because it is inserted in a passive way, it is important to check
. the contact point prior to cementation
Fracture preliminary to cementation When adjustments are needed, these should be carried out with
. the utmost caution as possible, as well as the pressure on the
. restoration during try-in and cementation
Poor positioning during cementation Since there is no defined end, a misguided insertion position is
. very common
Precision in the removal of overcontour after Como não há limitação de término, o laboratório deve enviar
cementation a restauração com sobrecontorno, que será removido após a
cimentação
Invariably, there is exposure of cement and removal of the glaze
Inadequate polishing
during the process
.
The mechanical behavior of the fragments depends on the
Delayed fracture
performance of the adhesive step
One way to minimize possible errors in the procedures is to establish clinical proto-
cols and follow them without compromise.
273
SELECTING THE CASE
It should verify the main complaint, the shade of the teeth and the possibility of ad-
ditive planning. At this stage is very important that the clinician make intra and extraoral
photographs as well as the initial impression taking with a polyvinilsiloxane (PVS) material,
for obtaining molds and study models for diagnostic waxing.
TRIAL OF THE PLANNING

Following the step of photographs, with the initial models, the ceramist dental te-
chnician (CDT) shall perform the diagnostic wax. For better visualization of small shape
changes, colored wax should be used on the stone model. The try-in procedure of the
diagnostic wax in the mouth is called mock-up, which is fundamentally important in aes-
thetic treatments.18,19 Two purposes make the mock-up a necessary step in aesthetic
treatments: to demonstrate a preview of the final work for approval by the patient and to
guide small reductions to be performed.20
To perform the mock-up a silicone wall is used, which copies the waxed stone model
to transfer the new shape obtained by the wax to the dental surface. A good wall should
cover all the waxed teeth and at least one non waxed tooth on each side. With all arch
subjected to waxing, the stability of the walls can be accomplished with small support in
the palate. It is also indicated to use a high viscosity silicone, more rigid, relined with low
viscosity silicone to copy every detail of the wax-up model. To better fit the wall the initial
impression taking should be carried out with a PVS material. It is suggested to ask the
technician to pour two models: one for waxing; and another for the patient to visualize
differences after the wax-up.
The material of choice for manufacturing the mock-up is a bis-acrylic resin, available
in cartridges, which must be dispensed and mixed with a gun and an auto-mixing tip. This
provides a more consistent polymer, without incorporation of air bubbles in the final mixtu-
re. The main features of this material which may be highlighted are: longer plastic phase;
little release of heat during polymerization; low shrinkage; fine-grained particles; excellent
polishing capacity; and low toxicity to the pulp.21-23
The silicone wall should be filled with resin and taken to the oral cavity. A slight finger
pressure should be carried out on the cervical region of the wall in the first minute.After
the 60-second period excesses may be removed. Each manufacturer has a specific time
for initial setting. On average it is necessary to wait four minutes for wall removal. When
the wall cutouts are performed accurately, merely polishing with felt disks needs to be
done. Following completion of the process, one can visualize the desired shape. It can be
seen in Tables 4 and 5 the specific materials and the check-list of the step as previously
described.
274
Table 4. Materials required for manufacturing the mock-up.
MATERIALS REQUIRED FOR MANUFACTURING THE MOCK-UP
1 Wax-up model
2 High- and low-viscosity PVS material
3 #12D scalpel blade and scalpel handle
4 Gauze soaked in alcohol
5 Flowable composite, similar shade to bis-acrylic resin
6 Bis-acrylic resin
7 37% phosphoric acid (if it is necessary leaving the mock-up in the mouth for more than 1 week)
8 Adhesive
9 Disposable applicator (eg Microbrush®)
10 Felt disc for polishing
11 Ocher, brown, white and blue dyes
12 # 00 brush for applying the dye
13 Polywave LED light-curing unit
Table 5. Checklist for manufacturing the mock-up.

CHECK-LIST FOR MANUFACTURING THE MOCK-UP
1 Initial impression with PVS material
2 Make sure that the wax-up was additive
3 Preserve an initial model
4 Use colored wax for small changes
5 Do not isolate the model
6 Fabricate the wall, at least 4 hours before use
7 Fabricate the wall in high-viscosity silicone and reline with low-viscosity silicone
8 Make the cut of the wall as close as possible from the cervical (1 mm excess of the margin). Contour the
. interdental papillae
9 Maintain a minimum thickness of 4 mm from the wall in the buccal region
10 Perform prophylaxis of teeth with pumice and rubber cup
11 Dismiss 8.0 mm of the bis-acryl resin before placing the material on the wall
12 Start inserting the resin on the wall with the tip of the gun touching the incisal aspect. Incisocervical placement
. direction
13 Straight insertion of the wall in an unique direction
14 Wait for 1 minute by pressing the cervical region
15 Remove the excesses after 1 minute
16 Remove the wall with caution
17 Remove the uncured layer with alcohol
18 Characterize with dyes (optional)
19 Perform polishing with dry felt discs
SHADE SELECTION
After defining the desired tooth shape through the mock-up based on the diagnos-
tic wax, it is necessary to perform some procedures prior to the final impression taking.
Accurate prophylaxis and removal of dental calculus must be performed, especially in the
proximal and palatal area. If possible, this procedure should be performed in an earlier
appointment for the impression because any potential gingival bleeding can impair the
manufacturing of the mold.
In jobs involving ceramic fragments, the tooth shade is crucial to the aesthetic
performance after cementation. For this, the first impression appointment procedure is to
perform the shade taking before any relevant tooth dehydration from the treatment.24 Then
the necessary materials and check-list for performing the shade-taking can be observed
(Tables 6 and 7).
275
Table 6. Materials required for shade taking.
MATERIALS REQUIRED FOR SHADE TAKING
1 Photographic camera
2 VitaClassical® shade guide and shade guide for bleached teeth
Table 7. Check-list for shade taking.

CHECK-LIST FOR SHADE TAKING
1 Make sure if the tooth is clean and free from calculus
2 After bleaching, wait for seven days for stabilization of color
3 Preferably, shade taking should be performed between 10am and 2pm. The photo shooting should be
outermost containing lips and skin, for observation of the interaction of the assembly with light
4 Use the shade guide horizontally and in the same inclination of the tooth long axis, touching it
SELECTIVE PREPARATION
When there is presence of retentive and sharp angles, minimal wear limited to the
surface enamel is necessary.25 Visual inspection followed by demarcation with pencil of
the undercuts in the tooth structure functions as a preparation guide for establishing the
insertion axis of the ceramic restorations. Additionally, for some cases, the CDT can per-
form a small wear on the initial guide stone model, which will be inserted on enamel for
removing undercuts.26-28 The grinding should be performed with a fine-grained diamond
tip, followed by polishing with sandpaper discs.
IMPRESSION TAKING
For making indirect restorations, PVS is the choice between the impression materials
(See Chapter 8). The superior clinical performance of this material is due to: tear resistan-
ce; low viscosity; dimensional stability; high capacity of elastic recovery; and the possibility
of pouring twice. Obtaining a good antagonist stone model helps the accurate occlusal
adjustment. For this reason, a PVS should be used for molding both arches.29,30
Ideally, the two impression step must be used to obtain an accurate copy of tooth
structure and gingival margin. However, the fundamental care should be retraction of the
gingival margins for the impression.24
As a rule, when the retraction cord is inserted, retraction of the gingival margin takes
place, which is suitable only for ceramics with cervico-vestibular termination. In the case
of ceramic fragments, changing the cervical margin may produce overcontoured restora-
tions. A final artificial appearance is thus obtained and, possibly, change of natural emer-
gence profile. Ultimately, there may still be tissue inflammation and gingival recession. To
avoid this, the ideal is always to perform the impression of fragments without retraction
cord, keeping the gingival margin in the natural position. However, the use of retraction
cord in the proximal surfaces is essential in cases of diastema or when you want to create
a new emergency profile throughout the cervical extension. The materials required and the
check-list for carrying out an accurate impression are described in Tables 8 and 9..
276
Table 8. Materials required for impression taking.
MATERIALS REQUIRED FOR IMPRESSION TAKING
1 Retraction cords (#000, #00, #1) (eg, Ultrapack®, Ultradent, USA)
2 Packing instrument or composite spatula (eg Cosmedent® IPC-L or similar)
3 Hemostatic agent (eg Viscostat Clear®, Ultradent, USA)
4 High- and low-viscosity PVS impression material, gun dispenser, self-mixing and intraoral tips
5 Rigid metal trays (never use aluminum trays)
6 Gauze
Table 9. Check-list for impression taking.

CHECK-LIST FOR IMPRESSION TAKING
1 Make sure that the gingiva is healthy, so there is no bleeding. If deemed necessary, prescribe chlorhexidine
. mouthwash during the 15 days prior to impression
2 Make sure that there is space in the tray for the material; between the labial of the first molar and the tray there
. must have 8 mm for accommodation of the material
3 Choose the caliber of the retraction cord in accordance with periodontal biotype. The thinner biotype the thin is
. the cord
4 Apply the hemostatic agent and remove excess astringent with dry gauze prior to packing into the gingival
. sulcus. The thinner the spatula the better will be packing and lower pain sensation.
5 In the two- step impression technique, move the tray with the high viscosity silicone within the first 2 minutes
. after insertion into the mouth for creating spaces for the low-viscosity impression material
6 Remove the high-viscosity impression material, and the retraction cords
7 Dispense with the low viscosity material in the mouth and tray
SELECTION OF THE CERAMIC MATERIAL

There are different materials for making fragment-type restorations. Dissilicate cera-
mics are indicated for occlusal and palatal restorations. These types of restorations can
be produced by injection or CAD/CAM. On the other hand, the feldspathic ceramic must
be sintered on a refractory stone model. The technique of preparation of this ceramic type
is manual, performed by of powder and liquid increments. Injected or milled ceramics in
small thicknesses are monochromatic and have many glass particles in its composition,
making it more translucent in small thicknesses. Consequently, they have low value (de-
gree of brightness), which can result in grayish look or translucent at best. When compa-
red to disilicates, refractory ceramics show higher amount of feldspar and quartz in their
composition. Additionally, they may be stratified since the first layer, and may receive a thin
opaque ceramics, providing opaque or translucent areas even in small thicknesses. When
fragments are manufactured to recover the canine guidance or the occlusal surface, it is
interesting to use lithium disilicate due to increased toughness.31 It is worth mentioning
the need for polishing after grinding ceramics which was previously adjusted in the mou-
th, since the high hardness of lithium disilicate combined with the high roughness of the
restoration after occlusal adjustment can cause excessive wear of the opposing tooth.32
Table 10 shows the comparison of the major differences between ceramics.
277
Table 10. Characteristics of injection molded versus refractory ceramics.
INJECTED REFRACTORY
Strength 380 MPa 90 MPa
Accept repairs Yes No
Light transmission Lower Higher
Cementation Ease of manipulation Dificuldade
Hardness Higher Lower
Costs Lower Higher
Time of fabrication 1/3 1
Adjustments of internal adaptation Usual Hard
TRY-IN OF THE RESTORATIONS

The session should start with prophylaxis of the tooth structure with rubber cups or
Robson brushes and pumice, is important to take special attention in the proximal areas,
this is the point with greater accumulation of bacterial plaque. If there is calculus in the pro-
ximal region a proximal metal strip should be used to remove calculus, with smooth mo-
vements, avoiding cuts in the gingival region. Trying-in ceramic fragments is an extremely
meticulous procedure that requires delicacy and rigorous care.33 The following guidelines
should be followed.
Observe the insertion axis: it is a great help to train the precise movement of insertion
and correct positioning of the restoration in the stone model. To feel secure, the clinician
repeats the movement to take the fragment on the natural tooth without performing pres-
sure on the restoration. If any interference prevents the correct placement of the restora-
tion, remove the perceived retention in the tooth, but never in the ceramic intaglio surface.
In this way, fractures and cracks are avoided.
Evaluate the point of contact: the adjustment process of the contact point is of
extreme importance and fragility. It must therefore be precise and be carried out with the
support of the restoration in hand or stone die.34 It is necessary that the professional have
security in small movements that will be performed.
There are resin cements with value and saturation options. These cement systems
have try-in “cements”, which are glycerine gels, with coloration corresponding to the op-
tical effects of the resin cement. The use of these proof or try-in pastes, as are commer-
cially called can be made to correct small changes in value. This step should, however,
be visualized with great care, because the restorations are extremely thin, and the shade
used wrongly can be disastrous. Therefore, one should give preference to translucent
shades of the cement. However, in bleached teeth can be used to tests high value try-in
cement, whereas the bleached tooth has a higher value (brightness).
CEMENTATION
Choosing the luting agent
Exclusively light-cured resin cements are of choice for cementation of fragment-type
restorations.35 Relevant features deserving attention are: greater color stability; higher
working time; and lower viscosity. With the great aesthetic demand and the evolution of
materials for cementation it is possible to choose between light-curing cements based on
a value scale rather than chroma, unlike other traditional light-curing cements, which, as
278
a rule, are based on the VitaClassical® shade guide (Vita, Germany) as color reference. In
addition to the option working with different degrees of lightness (value), The exclusively
light cured cements have alternative photoinitiators in their composition and, therefore, are
more translucent and less yellowish. However, they should be polymerized with different
wavelengths. In general, these cements are composed of alternative initiators such as
lucerin, Bis Acyl Phosphine Oxide (BAPO) and Phenyl Propanedione (PPD). The lower
viscosity facilitates the insertion of ultrafine restorations and prevents their fracture during
the bonding step. Is worth noting that the curing of these cements should be performed
by third-generation polywave-type LEDs, because they have different lamps with range
between 385 nm and 515 nm, which ensures the reaction of alternative initiators such as
lucerin, BAPO and PPD.
Cautions for luting ceramic fragments

Fragment-type ceramic restorations can be cemented off their proper seating. Becau-
se it is a mode that does not advocate conventional preparation of teeth, it has more than
one insertion axis. To prevent the restorations being cemented wrongly, extreme caution du-
ring positioning and care in the removal of excess cement before polymerization is required.
Professionals should also be positioned at different angles to view the restoration after inser-
tion and prior to curing. It is recommended that the clinician place at 12, 3, 6 and 9 hours to
check every angle of the restoration in the mouth before light-curing.
In case of cementation of multiple restorations to be performed simultaneously. Whe-
never the centrals are involved, they should be the first to be placed to avoid errors in the
region. Table 11 shows the materials required for cementation.
Table 11. Materials required for cementation.

MATERIALS REQUIRED FOR CEMENTATION
1 10% Hydrofluoric acid
2 37% Phosphoric acid
3 Pumice
4 Ultrasonic bath
5 Disposable applicatiors (eg Microbrush®)
6 ICB brush
7 #1 flat brush
8 Circular scalpel handle and # 12, #12D or #11 blades
9 PTFE tape
10 Dental floss
11 Proximal strip for composite resin polishing
12 Light-curing adhesive
13 Veneer type light-curing resin cement and try-in pastes
14 Silane
15 Ultrasound for tooth cleaning
16 Indented metal strips (Komet® or TDV®)
17 Hemostatic (Viscostat Clear®, Ultradent, USA), aluminum chloride type
18 Polywave-type curing light (eg BluePhase®, Ivoclar Vivadent, Liechtenstein)
279
Preparation of the ceramic restoration
Hydrofluoric acid etching of ceramic fragments should be performed with caution
because of their fragility. Importantly, etching should be performed after try-in of the res-
toration.
Step by step for the preparation of the restoration

1. Application of 10% hydrofluoric acid on the internal area of the restoration: After
the etching time, remove the acid in tap water with extreme caution so as not to
fracture the restoration.
Note that the etching time for each ceramic is different because of the amount of si-
lica that each system has. The purpose of etching with hydrofluoric acid is exposing
silica present in the spatial arrangement at the surface of the ceramic restoration. This
available silica will be reactive to silane. Furthermore, it will create microporosities.
Table 12 describes the etching time for each ceramic.
Table 12. Exposure time of ceramics to hydrofluoric acid.

FELDSPATHIC WITH LEUCITE (ON REFRACTORY) LITHIUM DISILICATE (e.max®)
Hydrofluoric acid - 90 to 120 seconds Hydrofluoric acid - 20 seconds
Contains apatite and leucite crystals Microstructure 70% Li2Si2O5
Composition SiO2 50-65wt% Spatial arrangement can be impaired due to excessive
exposure to hydrofluoric acid
Composition SiO2 57-80 wt%
After rinsing and drying a white, opaque surface will be obtained. At this moment,
there is loosened silica of the structure and residues that must be removed with one
of the following.36
2. Restoration cleansing: a new air/water spray for thorough rinsing of the restoration
and removal of etching debris.
3. Silanization: the silane is applied to the etched surface and dried for at least 60
seconds. The application protocol of acid and silane varies between commercially
available materials. Therefore, before using the cementation system, it is necessary
be informed about the protocol recommended for each system.
Preparation of the tooth structure

1. Prophylaxis with pumice and Robinson brush.
2. Packing of a #000 retraction cord mildly soaked in hemostatic (Viscostat Clear® ,
Ultradent, USA) (clear - aluminum chloride containing). Importantly remove excess
hemostatic with gauze.
3. In the substrate, etching should be performed with 37% phosphoric acid for 30 se-
conds, in enamel, followed by rinsing with water jet and air drying.
4. The adhesive system is applied to the tooth surface which has been properly et-
ched. After application of the adhesive system, excesses should be removed with
the aid of a suction cannula and air jet is applied for evaporation of the solvent.
280
5. After seating the restoration on the tooth, the excess cement must be removed with
the aid of brushes, dental floss and an indented metal strip. The initial curing for 3
seconds must be performed immediately after the previous phase. Note that removal
with a brush before light curing aids in the formation of a line of continuous adhesion.
As a result, there will be less bacterial colonization37 and there will be no gap forma-
tion from cement loosened with a explorer after initial polymerization.38
6. Removal of excess and application of glycerol to eliminate the inhibition layer and
complete polymerization for 40 seconds on each side.
7. Removal of the cord and excesses with scalpel blade.
FINISHING AND POLISHING

Characteristics of the ceramic-tooth interface after cementation
As mentioned, the overcontour of ceramic partial restorations should be removed after
completion of the cementation step. Failure to remove excess ceramic can generate, in addi-
tion to the aesthetic compromising, food impaction, higher accumulation of plaque, difficulty
of cleaning and consequent gingival inflammation. Poor polishing may lead to staining of the
adhesive interface and bacterial adherence. Thus, one must remove the over-contour by
means of finishing techniques and thorough polishing of the region throughout the restoration
interface.
Devoting the next appointment for the finishing and polishing step is recommended.
When carrying out the grinding of the restoration, a part of enamel and glaze applied to
the restoration is removed. These grindings are irreversible and therefore should be per-
formed accurately and meticulously. The adhesive interfaces can be classified into vertical,
horizontal and mixed.33
Vertical interface - It is characterized when the ceramic restoration has the largest
area of the parallel interface to the long axis of the teeth (eg, closing diastema).
Horizontal interface - In this case, the ceramic restoration has the largest area of
the interface perpendicular to the long axis of the teeth (eg, correction of the incisal edge).
Assemblies with mixed interfaces - When the ceramic restoration has perpendi-
cular and parallel interfaces over tooth axis (eg, diastema closure associated with class IV
type lesions).
Finishing sequence at different interfaces

At this stage, extra fine diamond burs are needed to finish at the termination of the
restoration, which should be performed with movements perpendicular to the ceramic
step. With this will be avoided the formation of depressions and undesired concavities.
Precise movements and magnification are extremely important in this process. The fi-
nishing should be guided according to the classification of each interface.
281
Vertical interface - To perform the motion perpendicular to the interface with the
step, it is necessary to tilt the head of the multiplier by 90°.
Horizontal interface - Similarly, one should use the diamond tip perpendicular to the
step. When carrying out finishing this type of interface you can find it difficult to insert or high
speed or multiplier due to the position of the adjacent teeth, in which case it will be neces-
sary to perform movements parallel to the step. With that the procedure becomes more
risky. One should pay more attention to the motion of the diamond instrument, which must
be in the ceramic-tooth direction. The grindings can be performed without irrigation with jets
of air, to enable viewing the interface and prevent potential concavities.
Mixed interfaces - There are situations where the edge of the ceramic restoration or
even grinding the vertical or horizontal step creates a mixed interface, situation very common
in canines, due to their larger volume in the middle third. When acting in mixed interfaces is
indicated to divide the step line into segments and to apply the technique of the vertical and
horizontal interface according to the position of each segment of the step.
The diamond points should be fine, good origin and new. Ideally each bur should be
used no more than 9 times, to maintain cut quality. Figures 1 and 2 can observe different
cuts of diamond points subjected to scanning electron microscopy.
As shown in the micrograph, thick grained burs should be avoided due to excessive
cutting capacity, which would generate an extremely scratched surface.
The interface finishing is considered complete when the fragment and the tooth
structure are in continuity,16 without a step and properly polished. Clinically, a deep slope
can be felt directly with the explorer. However, at the microscopic level can be observed
small unevenness in the line of continuity between the ceramic, the luting material and
enamel. Figure 3 shows the enamel surface after removal of the ceramic step. Note that,
after finishing, the tooth-restoration assembly features grooves and partial removal of the
ceramic glaze.
In the pictures below (Fig. 4 and 5) it can be observed at higher magnifications the
efficiency of finishing in the removal of the step formed in a vertical interface, immediately
after cementation.
Final polishing
The goal of the polishing procedures is to reduce the surface roughness, making it less
scratched gradually until the entire length becomes glossy. The greater surface smoothness
leads to a brighter surface, which aids in the aesthetics. Moreover, it tends to decrease plaque
adhesion and increase the longevity of the restoration.
While it is important, it is noteworthy that the polishing with rubbers is unable to give
back to initial smoothness of the restoration obtained with glaze of ceramics, which unfor-
tunately had to be removed during the finishing process.39
282
Figure 1. Figure 2.
Figure 1. SEM micrograph of a new diamond tip under 81x magnification.

Figure 2. SEM micrograph of diamond points of four different grits at 10X magnification.
Figure 3. SEM micrograph of ceramic fragment and continuous adhesive line after finishing with extra-fine grit diamond point under 14x magnification.
Figure 4. Scanning electron microscopy of the adhesive interface before finishing procedures. Note the angulation of the step immediately after cementation under 30x magnification.
Figure 5. SEM micrograph immediately after finishing with extra fine diamond points. Notice the zero angulation in the adhesive interface, which proves the removal of the ceramic step. 30x magnification.
The quality of the polishing rubbers and their life time are of primary importance. With
continued use, the diamond comes off of the their surface, reducing the polishing capacity
and generating a surface with less smoothness and shine. Each rubber system has its
respective order of granulation which should be followed according to the rules of each ma-
nufacturer. Next, Tables 12 and 13 which contain the necessary materials and the check-list
for finishing.
283
Table 13. Materials required for finishing.
MATERIALS REQUIRED
1 Crayons or graffiti for demarcation of edges and reflection angles (fine tip)
2 Fine-grained conical-shaped, rounded end diamond points
. (2200F, 2135F and 2135FF)
3 Multiplier
4 FF diamond point, flame shaped, for palatal surface
5 Miniflex diamond discs for finishing of the incisal embrasures
6 Rubber kit for finishing and polishing of ceramics (Professor Victor Clavijo® bur set, Shofu, Japan)
7 Drawing compass
8 Contra-angle
9 Straight handpiece
Table 14. Check-list for finishing and polishing.

CHECK-LIST FOR FINISHING AND POLISHING
1 In the case of multiple teeth, make the finishing and polishing in another session
2 Use magnification whenever possible. Choose loupes with 3.5x increase on average
3 Check the necessary adjustments in multiple directions in 3, 9, 6 and 12 hour positions
4 To adjust the incisal edge, always make movement with the rubber on the lingual aspect by 45º, avoiding
. grinding the edge by buccal
5 Make sure that the occlusal contacts are balanced and there is no premature contacts
6 Make all movements with the bur in only one direction. Avoid going back and forth movements with the bur in
. rotation
7 As the mirror areas of homologous teeth need to be identical, check the size of the areas of reflection and light
escape with the drawing compass.
A 34 year-old male patient, dentist, attended the clinic with aesthetic complaint from
CLINICAL
CASE
anterior superior segment due to the presence of composite resin restorations with color
deficiency and shape. After clinical and radiographic examination, it was diagnosed that
the restorations were with satisfactory adaptation, and the problem was solely aesthetic.
Upon photographs and study models, it was possible to plan the removal of resins of the
elements 13, 12, 11, 21, 22 and 23, together with the production of ceramic fragments in
the mesial surfaces of elements 13, 12, 22 and 23. The clinical protocol carried out was
described in this chapter.
Figure 6. Initial photography. Patient displays unsatisfactory composite resin restorations on anterior teeth, necessitating replacement.
Figure 7.Removal of the restorations with scalpel blades.
Figure 8. After the conservative removal of fillings, the remaining enamel presents visually intact.
284
Figures 9 and 10. A favorable geometry for the insertion axis of the ceramic fragments on the mesial surfaces of elements 13, 12, 22 and 23 is observed.
Figure 11.Smoothing small sharp angles with sandpaper discs (Sof-Lex Pop-On®, 3M ESPE, USA).
Figure 12. Small caliber retraction cords (#000, Ultrapack®, Ultradent, USA) in place to carry out a double cord technique in the proximal regions, to establish a new emergency profile.
Figures 13 and 14. Retraction cords of larger caliber (#0, Ultrapack®, Ultradent, USA) in place to carry out the double cord technique in the proximal regions, in order to create a new emergency profile.
Figure 15. Impression finalized by the double step technique and a vinyl polysiloxane material (Virtual®, Ivoclar Vivadent, Liechtenstein).
Figure 16. Prepared stone model, sectioned for the fabrication of model of alveolar dies.
285
Figure 17.Refinement of dies to create taper for the fabrication of the alveolar model.
Figure 18. Polishing of the dies to facilitate the adaptation on the alveolar model.
Figure 19. Confection of notches in the dies to create an insertion axis.
Figure 20. Sectioned dies for making the model. The “Alveolar Model” Technique.
Figure 21. Dies in position on the impression. Note the fixation of dies with orthodontic wire and acrylic resin to maintain the correct position.
Figure 22. Alveolar model finished.
286
Figure 29 a. Figure 29 b.
Figure 23. Fitting of the dies in the alveolar model.

Figure 24. Duplication of dies for making diagnostic wax-up, which will assist in the application of the dental ceramics.
Figure 25. Preparation of diagnostic wax-up by addition.
Figure 26. Finishing of the diagnostic wax-up by addition.
Figures 27 and 28. Final result of the diagnostic wax-up by addition.
Figure 29 a. Selected masses for layering of ceramic fragments.
Figure 29 b. Model dies in refractory die and the first ceramic layer (IPS D.sign®, Ivoclar Vivadent, Liechtenstein), opalescent mass E1.
287
Figure 30. Ceramic sealing completed. Note the homogeneous and smooth layer, obtained through burning 70 ° C above the normal temperature.
Figure 31. Stratification of the mesial aspect of the laterals. Mixture of opaque dentine masses DDA1 + DBL2 1:1. Mamellons, MMLight and Salmon. Incisal, TS2 and enamel E1 also involving the
mesioincisal contour. Transition angles E2. In canines only the substitution of the ratio, 2:1.The focus of the application and choice of the masses is to mimic the healthy tooth remnant.
Figure 32. After roughnening the entire ceramic surface one should define the reflection edges and make the necessary changes.
Figure 33. Cautious smoothing of the angles. An important step which defines the long axis and the proper tooth dimension.
Figure 34. After glazing manual polishing was performed. It is important that this step is accomplished prior to removal of the investment fragments.
Figure 35. Polishing with brushes and diamond pastes.
288
Figure 36. Observe the delicacy of the fragments.

Figure 37. Masses of ceramic correctly positioned. Proximal surfaces with sufficient opacity, labial surface with excellent effects of translucency and opalescence compatible with the tooth.
Figure 38. Restorations placed on the alveolar model.
Figure 39. Fragmentos ajustados no modelo sólido.
Figures 40 and 41. Ceramic fragment in position on tooth #12.
Figure 42. Fragments in position on the mesial surfaces of teeth 22 and 23.
Figure 43. Dry try-in of the fragments with the sole purpose to check the fit.
289
Figure 44. The fragment is hydrated simulating the use of clear or mean value cement.
Figure 45. Wet try-in of the fragments for checking shade and shape.
Figure 46. Try-in pastes (Variolink Veneer®, Ivoclar Vivadent, Liechtenstein) for increasing value. In sequence, mean value to high value +3. One can use small increases in value for bleached teeth.
Figure 47. Final check of the contact points with carbon paper.
Figure 48. Adjustment of the contact points with abrasive rubbers (Exacerapol®, Edenta, Switzerland).
Figure 49. Plaque removal in the proximal surfaces with sandpaper strip.
Figure 50. Prophylaxis of the region with pumice slurry.
Figure 51. Packing of the cord retraction prior to cementation.
Figure 52. Application of phosphoric acid at 37% for 30 seconds.
Figure 53. Thorough rinsing with water.
Figure 54. Application of the adhesive system.
290
Figure 55. Figure 56. Figure 57. Figure 58.
Figure 55. Ceramic rtching with 10% hydrochloric acid for 90 seconds.
Figure 56. Thorough rinsing with water.
Figure 57. After drying, there is a chalky layer related to the debris produced by etching.
Figure 58. Removal of the residue with abundant rinsing water or air/water jets.
Figure 59. It can be observed the removal of the chalky area.
Figure 60. Application of a thin silane coating.
Figure 61. Application of resin cement.
291
Figure 62. Insertion of the fragment with resin cement on the tooth structure.
Figure 63. Removal of excesses with the brush technique.
Figure 64. Light curing of the cement for 40 seconds on each surface (BluePhase®, Ivoclar Vivadent, Liechtenstein).
Figure 65. Removing the retraction cords.
Figure 66. Removing the interdental excesses with dental floss and a knot to create friction in the area, removing the excesses actively.
Figure 67. Cementation completed without aggression to the periodontal tissues.
292
Figure 68. Figure 69 a.
Figure 69 b. Figure 70.
Figure 68. Start of finishing delimiting the edges and vertical interface.
Figure 69 a. Removal of overcontour at the interface with extra-fine diamond point perpendicular to the long axis of the fragment.
Figure 69 b. “Victor Clavijo” Polishing Kit (Ceramisté®, Shofu, Japan)
Figures 70-72. Polishing of the interface with all of the rubber formats for dental ceramics (Kit “Victor Clavijo”, Ceramisté®, Shofu, Japan).
293
Figure 73.
Figure 74.
Figures 73 and 74. Observe the final result, which demonstrates the effectiveness of dental fragments technique.
294
1. Albakry M, Guazzato M, Swain M. Facture Toughness, Microstructure And Toughening Me-chanism Of Leucite And Lithium
REFERENCES
Disilicate Glass Ceramics. Key Eng Mat. 2003;240-242:955-8.
2. Anami LC, Pereira CA, Guerra E, Assunção e Souza RO, Jorge AO, Bottino MA. Morphology And Bacterial Colonization Of Tooth/
Ceramic Restoration Interface After Different Cement Excess Removal Techniques. J Dent. 2012;40(9):742-9.
3. Andrade OS, Borges GA, Kyrillos M, Moreira M, Calicchio L, Correr–Sobrinho L. Area Of Adhesive Continuity: A New Concept
For Bonded Ceramic Restorations. Quintessence Dent Technol. 2013;36:29-43.
4. Andrade OS, Romanini JC, Hirata R. Ultimate Ceramic Veneers: A Laboratory- Guided Ultra-conservative Preparation Concept
For Maximum Enamel Preservation. Quintessence Dent Te-chnol. 2012;35:29-43.
5. Anusavice KJ. Phillips Materiais Dentários. 11A. Ed. Rio De Janeiro: Elsevier; 2005.
6. Baratieri LN, Monteiro S Jr, Caldeira de Andrada MA. Tooth Fracture Reattachment: Case Re-ports. Quintessence Int.
1990;21(4):261-70.
7. Buonocore M. A Simple Method Of Increasing The Colhesion Of Acrilic Filling Materials To Enamel Surface. J Dent Res.
1955;34:849-53.
8. Calamia Jr, Calamia CS. Porcelain Laminate Veneers: Reasons For 25 Years Of Success. Dent Clin North Am. 2007;51(2):399-
417.
9. Calamia Jr. Etched Porcelain Veneers: The Current State Of The Art. Compend Contin Educ Dent. 1998;19(6):625-8, 630, 632
Passim; Quiz 638.
10. Cardoso PC, Luz CA, Magalhães APR, Perillo MV, Monteiro LJE, Decurcio RA. Facetas Cerâmicas: Como Remover Os Exces-
sos Do Cimento Resinoso? Clínica - Int J Braz Dent. 2013;9(3):252-8.
11. Chosack A, Eidelman, E. Rehabilitation Of A Fractured Incisor Using The Patient’s Natural Crown- Case Report. J Dent For Child.
1964;31(1):19-21.
12. Clavijo V, Calicho LE, Kyrillos M, Moreira M, Oliveira H. Visão Clínica: Fragmentos ce-râmicos: o estado da arte. Clínica - Int J
Braz Dent. 2011;7(4):378-85.
13. Clavijo V, Kabbach W, Bocabella L. Restaurações Cerâmicas Com Mínimo Preparo Dental. Beleza Do Sorriso CIOSP 2013.
14. Clavijo V, Kabbach W. Fragmentos E Lentes De Contato: Detalhes Que Fazem A Diferen-ça: Treine Seus Olhos. Clínica - Int J
Braz Dent. 2013;9(3):252-8.
15. Clavijo V, Kabbach W. Restaurações indiretas em cerâmica- Faceta sem preparo dental (lentes de contato). Clínica - Int J Braz
Dent. 2012;8(4):374-85.
16. Clavijo VRC, Cavaretti MH, Beltrán MC, Ferreira LA, Andrade MF. Fragmentos cerâmi-cos. Clínica - Int J Braz Dent. 2010;6(3):290-9.
17. Duarte Jr S. Ceramic Reinforced Polymers: Overview of CAD/CAM Hybrid Restorative Materials. Quintessence Dent Technol.
2014;32-48.
18. Fradeani M, Redemagni M, Corrado M. Porcelain Laminate Veneers: 6- To 12-Year Clini-cal Evaluation. A Retrospective Study.
Int J Periodont Restor Dent. 2005;25(1):9-17.
19. Friedman MJ. A 15-Year Review Of Porcelain Veneer Failure a Clinician’s Observations. Int J Prosthodont. 2007;20(4):389-96.
20. Gresnigt M, Mutlu Özcan. Aesthetic Rehabilitation Of Anterior Teeth With Porcelain Lami-nates And Sectional Veneers. J Can
Dent Assoc. 2011;77:b143.
21. Gurel G, Sesma N, Calamita MA, Coachman C, Morimoto S. Influence Of Enamel Preser-vation On Failure Rates Of Porcelain
Laminate Veneers. Int J Periodont Restor Dent. 2013;33(1):31-9.
22. Gürel G. Porcelain Laminate Veneers: Minimal Tooth Preparation By Design. Dent Clin North Am. 2007;51(2):419-31.
23. Gürel G. Predictable, precise, and repeatable tooth preparation for porcelain laminate vene-ers. Pract Proced Aesthet Dent.
2003;15(1):17-24, 26
24. Hill E. Dental Cements For Definitive Luting: A Review And Practical Clinical Considera-tions. Dent Clin North Am. 2007;51(3):643-
58.
25. Horvath S, Schulz CP. Minimally Invasive Restoration Of A Maxillary Central Incisor With A Partial Veneer. Eur J Esthet Dent.
2012;7(1):6-16.
26. Kurtzman GM, Strassler HE. Provisional Fixed Restorations. Dental Economics. 2006;3:1-12.
27. Kyrillos M, Moreira M. Sorriso Modelo: O Rosto Em Harmonia. São Paulo: Ed. Santos, 2004.
28. Layton DM, Walton TR. An Up To 16-Year Prospective Study Of 304 Porcelain Veneers. Quintessence Int. 1985;16(1):5-12.
29. Layton DM, Walton TR. The Up To 21-Year Clinical Outcome And Survival Of Feldspathic Porcelain Veneers: Accounting For
Clustering. Int J Prosthodont. 2012;25(6): 604-12.
30. Lieu C, Nguyen TM, Payant L. In Vitro Comparison Of Peak Polymerization Temperatures Of 5 Provisional Restoration Resins. J
Can Dent Assoc. 2001;67(1):36-9.
31. Magne M, Bazos P, Magne P. The alveolar cast. Quintessence Dent Technol. 2009;32:39-46.
32. Magne P, Belser U. Bonded porcelain restorations in the anterior dentition: a biomimetic approach. Chicago: Quintessence;
2002.
33. Magne P, Hanna J, Magne M. The Case For Moderate “Guided Prep” Indirect Porcelain Ve-neers In The Anterior Dentition. The
Pendulum Of Porcelain Veneer Preparations: From Almost No-Prep To Over-Prep. Eur J Esthet Dent. 2013; 8(3):376-88.
34. 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(1):10-9.
35. Magne P, Willian D. Additive contour of porcelain veneers: a key element in enamel pre-servation, adhesion, and aesthetics for
aging dentition. J Adhes Dent. 1999;1(1):81-92.
36. Patterson CJ, Mclundie AC, Stirrups DR, Taylor WG. Refinishing Of Porcelain By Using A Refinishing Kit. J Prosthet Dent.
1991;65(3):383-8.
37. Perakis N, Belser UC, Magne P. Final Impressions: A Review Of Material Properties And Description Of A Current Technique. Int
J Periodont Restor Dent. 2004;24(2):109-17.
38. Signore A, Kaitsas V, Tonoli A, Angiero F, Silvestrini-Biavati A, Benedicenti S. Sectional Porcelain Veneers For A Maxillary Midline
Diastema Closure: A Case Report. Quintessence Int. 2013;44(3):201-6.
39. Strassler HE, Anolik C, Frey C. High-Strength, Aesthetic Provisional Restorations Using A Bis-Acryl Composite. Dent Today.
2007;26(11):128, 130-3.
295
chapter 7
ceramic systems
Júnio S. Almeida e Silva | Juliana Nunes Rolla
Restorative dentistry has undergone a revolution over the last thirty years not only
INTRODUCTION
related to the advent of new materials and techniques, but also linked to scientific eviden-
ce endorsing their use. The principle that guided the dental restorative therapies until now
was strictly based on clinical performance, rather than the aesthetic quality inherent to
the restorative material. Arguably with excellent clinical durability, gold alloy and amalgam
restorations have been widely used both in the posterior as well as in anterior teeth, even
though their appearance represented aesthetic discomfort to the patient.18 However, since
the introduction of the first successful porcelain-fused-to-metal system,86 there is incre-
asing demand for ceramic restorations because this is an aesthetic material with optimal
properties due to the availability of a range of shades and translucency effects. Further-
more, historically, the aesthetics of ceramics had an inversely proportional relation to the
mechanical properties and therefore, the first ceramic systems were necessarily fused
to a metal infrastructure to increase the fracture resistance.73 However, this metal base
could affect the aesthetics of the restoration by reducing the transmission of light through
the ceramic, which may cause gingival darkening in the cervical region of the restoration,
termed “the umbrella” effect” 4
(Fig. 1). This disadvantage, alied to increased aesthetic
requirements and the evolution of ceramic materials, led to a new era, which boosted the
production of fully functional, durable and yet aesthetic ceramic restorations. Currently,
when properly indicated, dental ceramics represent the restorative option with a better
capaciity to reproduce the intricate optical effects of natural teeth, as well as to simulate
and restore tooth rigidity, restablishing its biomechanical properties.59,60
The clinical performance of all-ceramic crowns and veneers have been succes-
sful and clinically tested.20,23,71,69,84,43,63,80 So when restoring anterior teeth, the modern
all-ceramic systems are an excellent treatment option for fixed prostheses, crowns and
veneers.59,20 However, treatment planning influenced by media, products not yet correctly
tested, but commercially available, and the patients’ desire to satisfy their aesthetic de-
mands have formed a dangerous combination with little regard to the analysis of risk-be-
nefit of dental treatment.75 Indeed, the excessive application of ceramic veneers has been
demonstrated and has probably been due to the development of reinforced ceramics,
which led to a wider range of indications.Accordingly, traditional preparations designs for
veneers have become extended designs driven by the defect of the tooth to be restored.
These extended veneer preparations can be an alternative to crowns in the anterior den-
tition.84,16,17,19
Independent from the proven clinical success of all-ceramic veneers and crowns59,20
as well as any restorative procedure, from the moment they are cemented, the teeth are
inserted into a restorative cycle.78,12 All-ceramic crowns have been extensively used in
recent years due to longevity being comparable to PFM crowns, reaching impressive
98.8% clinical success rate after 11 years of service.59,20,13,20 The main causes of failures of
these restorations involve catastrophic fractures, chipping of the veneering ceramics and
secondary caries.59 Despite the fact that ceramic veneers when compared to crowns na-
turally involve a minimally invasive approach it is not clearly true that less tooth reduction by
298
means of less invasive preparations will always result in an increased longevity of ceramic
restorations. In this context, it was demonstrated that reinterventions without replacement
of 36% of the teeth with ceramic veneers and retreatment with crown replacements of
approximately 7% of cases occured after 10 years of clinical service.35,27 The main cau-
ses of failure of ceramic veneers are fracture, microleakage and cementation failure. This
means that the ceramic veneers, especially if inaccurately indicated, are restorations more
susceptible to future interventions than are ceramic crowns.
Therefore, it is crucial that clinicians be aware of the correct indication of these res-
torations to provide them optimal longevity.12 Thus, neither the ceramic crowns or veneers
should be the first choice in all cases, since several factors need to be considered in the
preparation of treatment planning including previous ceramic restorations. In this chapter, a
classification, according to the composition of dental ceramics is described. Yet, important
considerations are addressed based on evidence related to the rehabilitation treatment
planning in anterior teeth with crowns and ceramic veneers.
Porcelain-fused-to-metal All-ceramic
Figure 1.
Figure 1. Schematic illustration of the effect “umbrella” in the gingival cervical region caused by improper relationship of metal with light.
299
The term “ceramic” is derived from the Greek, Keramos, meaning “burned matter”.
CERAMICS
Ceramic comprises any inorganic class of solid, non-metallic material that is subjected to
high temperatures during its manufacturing. Ceramic is the oldest of the industries. It was
born at a time when man began to use fire-hardened clay in making pots for storing water
and food. This process of hardening obtained casually, has multiplied, evolved. Currently,
in addition to its use as a constituent raw material for various household tools and civil
construction, and as a plastic material in the hands of artists, ceramics are also used in
high technology. Porcelain, a specific type of ceramic widely used for approximately 3
thousand years, is a blend composed of three minerals: white clay (calium), quartz and fel-
dspar. When these three ingredients are pulverized, mixed, molded and fired, they beco-
me the white ceramic known due to staining acquired after the firing process. Porcelain is
a type of white ceramic which possesses a relatively high strength and translucency. White
ceramics comprise a wide range of products such as cutlery and porcelains (utilitarian
and decorative), sanitary, technical porcelain and for dental use, which differ, among other
factors, by the firing temperature, composition of the mass and the type of melting.34,50
There are different types of ceramics for dental application as well as different classi-
fication systems and indications. In this chapter, the current ceramic systems are ordered
according to their main composition. Dental ceramics may be divided into vitreous, parti-
cle-reinforced and polycrystalline.50
GLASS
CERAMICS
In 1962, Weinstein & cols.86 found that, by heating a certain type of feldspar rock
containing 11% potassium and rapid cooling, to form a glass. This glass, when reheated,
had a high coefficient of thermal expansion, because of the formation of a new crystal,
leucite. By developing this crystal, they discovered the first particle to reinforce modern ce-
ramics and, even more importantly, achieved through the incorporation of leucite crystals
in feldspathic ceramics, a novel ceramic, which possesses a similar thermal expansion
coefficient similar to that of metal. And so the first successful porcelain-fused-to-metal
restorations were successfully made.
Feldspathic ceramics is essentially a mixture of potassium feldspar (K2O.Al2O3.
6SiO2) or sodium feldspar (Na2O.Al2O3.6SiO2) and quartz (SiO2). These components
are heated at high temperatures (1,200 ºC to 1,250 ºC), and the incongruent fusion of
feldspar leads to the formation of a liquid glass of leucite crystals (K2O.Al2O3.4SiO2). The
molten mass is abruptly cooled to maintain the glassy state, which is basically constitu-
ted by a network of silica. After cooling, the mass is ground, and a powder is obtained.
The feldspar ceramic contains two phases: one glassy, responsible for the translucency
of the material, and the other crystalline, which confers resistance. Land57 introduced
the ceramic crowns in 1903, but the material was not very resistant, the fabrication tech-
nique was complicated, and the choice of cementation agents, restricted. Although they
were chemically stable materials and provide excellent aesthetics, they are essentially
brittle materials. The compressive strength of these materials is high (350 to 450 MPa),
but their tensile strength is very low (20 to 60 MPa), which is typical of fragile materials.
300
The inherently low tensile strength restricted their use to low loading situations of stress
in the anterior region (Fig. 2).85
Ceramics, being primarily a glass, does not present any fracture strength. Minute
cracks on the material surface act as initiation sites for catastrophic failure. Because it is
a brittle material, ie, presenting restricted ability for dissipate localized stresses, which are
concentrated at the edge of the cracks and thus promote their propagation through the
ceramic and consequently, the fracture of the material without the presence of plastic de-
formation. Knowing that the ceramic material fracture process is associated with the pro-
pagation of cracks in the material, whatever that might hinder or prevent propagation will
increase the intrinsic strength of the ceramics.85 For this purpose, filler particles began to
be added to the glass-ceramics, to improve properties such as strength as well as thermal
expansion coefficient. Highly aesthetic ceramics are predominantly vitreous. They are the
best materials for reproducing the optical properties of enamel and dentin, and are often
identified as veneering porcelain, which often are accompanied by a ceramic infrastructure
(polycrystalline or glass particle-reinforced) more suitable when jointly used.
Figure 2.
Figure 2. Example of feldspathic ceramics (Creation CC) being applied over refractory die for the manufacturing of a conventional veneer on tooth 21.
301
PARTICLE-REINFORCEMENT
REINFORCED
CERAMICS
In order to improve mechanical properties such as strength, thermal expansion and
contraction, manufacturers have added particles to the basic composition of the glass-
-ceramics. These particles are generally crystalline, but may also be high-melting glass
particles, which are stable at ceramic firing temperatures.49 Greater amount of leucite was
added to the feldspathic ceramic in order to increase its resistance. Approximately 55%wt
of leucite crystals were added to a glass matrix, which brings advantages such as the
absence of an opaque infrastructure, good translucency and the possibility of being used
without special laboratory equipment, since the technique for manufacturing these cerami-
cs is similar to that for feldspathic ceramics.49-51 Currently, the main and most widespread
product for leucite-reinforced ceramic restorations is the injection system IPS Empress
Esthetic and IPS Empress CAD (Ivoclar Vivadent, Liechtenstein) (Fig. 3 and 4).
LITHIUM DISILICATE PARTICLE-REINFORCED

IPS Empress 2 (Ivoclar Vivadent, Liechtenstein) is a lithium disilicate reinforced
ceramic (SiO2-Li2O), which is manufactured by combining the techniques of lost wax,
and heat and pressure injection. A ceramic block of the desired color is plasticized at
920 °C and injected into an investment ring under pressure and vacuum. IPS Empress 2
improved the flexural strength three times over IPS Empress and may be used for three-
-element fixed bridges in the anterior segment, until the second premolar. The infrastruc-
ture is layered with a fluorapatite-based veneering porcelain (IPS Eris, Ivoclar Vivadent,
Liechtenstein), resulting in a semi-translucent restoration with optimized light transmis-
sion. In 2005, the IPS e.max Press system (Ivoclar Vivadent, Liechtenstein) had been
launched, consisting of a lithium disilicate-based pressable ceramic superior than IPS
Empress 2. Due to a difference in the firing process, both the physical properties as well
as its translucency were improved, making it also feasible to be utilized as an aesthetic
veneering ceramic. The IPS e.max system is available for injection as well as CAD/CAM
technologies (Fig. 5 and 6). Two types of ingots are available for the injection technology:
IPS e.max Press, a lithium disilicate-reinforced ceramic and IPS e.max ZirPress, a lithium
disilicate glass reinforced ceramic for application over zirconia copings. For veneering,
the IPS e.max Ceram layering ceramic was developed, a novel type of ceramic, which
has a crystalline phase composed of nano- and micro-fluorapatite crystals.This may be
applied over all IPS e.max products.59,20,51 Generally, they are reinforcing particles which
are dissolved during etching, creating micromechanical retention to allow their adhesion
to dental tissue through the use of adhesives and resin cements. These particles may
be mechanically added during manufacturing as a powder or by precipitation inside the
glass matrix, through special nucleation and temperature increase processes.51
302
Figure 3. Figure 4.
Figure 5. Figure 6.
Figure 3. Ceramic ingots reinforced with approximately 55% of leucite crystals. IPS Empress ingots (Ivoclar Vivadent).
Figure 4. CAD/CAM ceramic block reinforced with approximately 55% of leucite crystals, IPS Empress CAD (Ivoclar Vivadent).
Figure 5. CAD/CAM ceramic block reinforced with lithium disilicate crystals, IPS e.max CAD (Ivoclar Vivadent).
Figure 6. Ceramic ingots reinforced with lithium disilicate crystals. IPS e.max Press ingots (Ivoclar Vivadent).
(GLASS INFILTRATED) ALUMINA-, MAGNESIUM- AND ZIRCONIA-REINFORCED

In-Ceram Alumina (VITA Zahnfabrik, Germany), introduced in 1989, was the first all-
-ceramic system designed for single restorations and anterior three-element fixed bridges.
In this system a highly resistant ceramic core manufactured by the “slip casting” techni-
que, which serves as the infrastructure. This provides flexural strength of 400 MPa and
a marginal discrepancy of 40 µm. The infrastructure is fabricated from a dense alumina
paste (70% to 80% vol.), which is applied on the stone die, carried to the furnace where
alumina sintering occurs at 1,120 ° C for 10 hours. This produces a scaffold of alumina
particles, which is infiltrated by glass in a second firing, at 1,100 ° C for 4 hours to remove
porosity, increasing the strength and limit the potential for crack propagation. Feldspathic
porcelain is applied over the infrastructure (Vitadur Alpha, Germany), since the high per-
cent of alumina makes the infrastructure very opaque. Alumina blanks (Vitablocks In-Ce-
ram Alumina, Vita, Germany) are also available for computerized (CAD/CAM) application in
combination with Cerec (Sirona, Germany).25,13,14,62
303
In 1994, In-Ceram Spinell (Vita, Germany) was introduced as an alternative to in-
-Ceram® alumina opaque core. It contains a mixture of alumina and magnesia (MgAl2O4)
within its structure, making it translucent. However, its flexural strength is 25% lower in
relation to in-Ceram alumina, and therefore the cores are recommended only for anterior
crowns. This material may also be made with Cerec Inlab, to be followed by veneering with
a feldspathic porcelain. In-Ceram Zirconia is also a modification of the original in-Ceram
Alumina system, with the addition of 35% zirconium oxide.7 A flexural strength of 750 MPa
(approximately 20% more than in-Ceram Alumina) allowing for the production of posterior
total crowns and three element fixed bridges, including the posterior areas on natural teeth
or implants. The traditional technique of “slip casting” may be used, or the core may be
obtained by partially sintered, prefabricated blocks, associated with a mechanized system
and then veneered with a ceramic feldspathic.59,7
These ceramics are exclusively produced by CAD/CAM technology and designed
POLYCRYSTALLINE
CERAMICS
for the production of structures in polylytic restorations, without a glass matrix in their
compositions. All of their atoms are condensed under regular arrangements, which makes
exceedingly this class of material more resistant to the propagation of flaws than glass-ce-
ramics or those containing a vitreous content in their composition.49,51
HIGH ALUMINA CONTENT

A natural evolution of alumina-reinforced systems considered the possibility of de-
veloping a pure alumina structure. There are at least two systems on the market that offer
pure alumina structures, Procera AllCeram (Nobel Biocare, Sweden) and InCeram AL sys-
tem. The main advantages are increased strength and superior light transmission when
compared to glass-infiltrated materials. Procera AllCeram was developed by Andersson
& Oden3, with copings containing 99.9% alumina, which provides an average flexural
strength of 650 MPa and marginal discrepancy below 70 µm. Combined with a low fusion
ceramics, the Procera system exhibits the highest strength among the alumina-based
materials, and less in comparison merely to those that are zirconia-based. This exclusively
uses CAD/CAM technology for building infrastructures and well suited for fabricating fra-
meworks of anterior and posterior full crowns, three-element fixed bridges for anterior and
posterior region.59,44 The coping of this ceramic is produced by a special process, which
involves sintering of 99.5% pure alumina from 1,600 to 1,700 °C, which is highly densified.
This is then sent to the laboratory for manufacturing the aesthetic portion of the crown,
using feldspathic glass, made compatible through the technique of natural stratification.59
Alumina copings for full crowns must have 0.6 mm thickness for posterior teeth
and 0.4 mm for anterior teeth. In the case of fixed prostheses, the area of the connector
between the bridge abutment and pontic must be 4 mm high and 3 mm wide. One of the
difficulties in glass-infiltrated and high alumina-content systems is that they do not allow
for etching of the ceramic surface to improve retention. Being that the fitting surface is
304
made of alumina, rather than silica, there are not any bonding agent available which can
effectively join ceramic structure to the resin cement. Without an effective bonding agent,
or an ideally micromechanically retentive surface, these systems may not be bonded to
the dental tissues with resins and thus are lacking all the benefits associated with ceramic
restorations using adhesive resin cements.57
HIGH ZIRCONIA CONTENT

Zirconia is a polymorphous material existing in three forms. At its melting point (2,680
ºC), the existing cubic structure transforms into a tetragonal phase (2,370 ºC).3,40 The
other transformation occurs at about 1,170 ° C and is accompanied by a volumetric ex-
pansion of approximately 3-5%, which causes high internal stress. Yttrium Oxide (Y2O3)
is added to the pure zirconia for controling the volumetric expansion and stabilizing the
material in the tetragonal phase at room temperature. The stabilization of the mechanical
properties of zirconia, such as its chemical and dimensional stability, and high mechanical
strength, is of interest for the restorative dentistry, especially when subjected to excessive
loads on the surface, some crystals stabilized in tetragonal form may metastasize back to
the monoclinic form, with an approximate increase of 4-5% vol., by acting like a sealant,
creating a localized “weld”, which prevents the propagation of failures more internally. This
particular phenomenon of zirconia is named toughening transformation41 (Fig. 7).
Figure 7.
Figure 7.CAD/CAM polycrystalline ceramic blocks with high zirconia content (inCoris ZI, Sirona).
305
The manufacturing process for machining zirconia structures may be performed
through two manufacturing strategies. Depending on the system, both densely sintered
zirconia blocks as well as semi-sintered blanks may be machined. Densely sintered zirco-
nia blocks are machined in the actual size of the structures. However, the high hardness
and friability of these blocks have certain disadvantages such as extended periods for
machining and an increased wear on the parts of the milling unit; and further, when using
these blocks, the machining of the thin parts of a structure is a difficult process.41,70 Semi-
-sintered blanks, on the other hand, are available in a semi-porous state and have “chalky”
consistency, being easier to be machined by the milling unit; thus causing less cohesive
fractures of the zirconia structures and less wear.40
However, after the machining of the semi-sintered blanks, the structures must then
be sintered in order to achieve its final density and the maximal mechanical properties of
the zirconia. This sintering process is characterized by a high sintering shrinkage of about
20% to 30%, which must be compensated for during the machining procedures as well as
the sintering shrinkage creates an additional challenge for the software, which is respon-
sible for the accurate calculation of a structure which is 20% to 30% larger than its actual
dimensions after sintering. Accordingly, the structure will contract precisely to the desired
final dimension after the sintering process.40,41 Despite the trend of milling fully sintered
blocks to promote better dimensional accuracy, CAD softwares have been effective in
compensating for the sintering shrinkage of zirconia.40,41,58 75,51
The Procera AllZirkon system (Nobel Biocare) contains a high zirconia content and a
flexural strength of 1,200 MPa. It is indicated for the fabrication of infrastructures for ante-
rior and posterior crowns, with application of a veneering feldspathic ceramic with compa-
tible thermal expansion coefficient. The laboratory phase is similar to Procera Allceram.75
The Cercon Zirconia system (Dentsply-Degussa) is indicated for the production of copings
for anterior and posterior full crowns, as wellas infrastructures of three- and four-element
FPDs of the anterior and posterior regions. The material is supplied in the form of semisin-
tered ceramic blanks. In this system the infrastructure is constructed in wax and scanned
with the laser unit of the Cercon system. The ceramic block is milled on a specific CAM
unit of the system and then sintered to a compact form at 1,350 °C for 6 hours. Low fusion
veneering ceramic is applied over the infrastructure (CerconCeram), with a coefficient of
thermal expansion compatible for application over zirconia.59
The Lava system (3M ESPE, USA) uses a zirconia infrastructure with a high flexural
strength, high fracture toughness and high modulus of elasticity when compared to alumina.
The stone model is scanned by an optical process, LavaDesign software is used to design
the structure, which is then fabricated using semi-sintered blocks. The restorations may be
colored with up to seven colors and then undergo sintering for 8 hours. Figures 8 and 9,
adapted from Della Bona & Kelly,23 show the main commercially available ceramic systems
for all-ceramic restorations, based on the matrix composition, concentration and type of filler
particles, manufacturing process and brand name.
306
MATRIX FILLER PROCESSING BRAND NAME
1. GLASS-CERAMICS
CEREC Mark II1
1.1 Aluminum-silicate glass High melting glass,
nepheline, albite or
(feldspar or synthetic) Triluxe1
(approx. 40%) InLab
Triluxe1 Forte1
2. REINFORCED CERAMICS
CEREC/InLab EmpressCAD2
2.1 Particle-reinforced Empress Esthetic2
leucite (40% - 50%) pressed
glass, high content of glass OPC3
Optec3
powder Cerinate4
Mirage5
CEREC/InLab e.max CAD2

lithium disilicate (70%)
pressed e.max Press2
2.2 Low glass content
(particlereinforced glass) InLab
In-Ceram alumina1
alumina, spinel,
or
alumina/zirconia (70%) In-Ceram spinel1
Dental Lab
In-Ceram zircônia1
3. POLYCRYSTALLINE CERAMICS
Dopping*
Mg 93%) InLab In-Ceram AL1
3.1 Alumina
grain growth control CAD/CAM Procera6
Y, Ce, Al (3% to 5%) In-Ceram YZ1
InLab
3.2 Zirconio increased transformation e.max ZirCAD2
CAD/CAM
toughness Lava7, Cercon8, Procera6
Figure 8.
MATRIZ FILLER PROCESSING BRAND NAME
1. GLASS-CERAMICS
Dies,
1.1 Veneering opaquers powder Vita VM7
(4% to 5%)
Vita VM9
powder
Leucite moderately IPS e.maxCeram
1.1 Press-on zirconia modified, chemical
dopants (5% to 10%)
Injection-molded IPS e.maxZirPress
Vita VM13, 15
powder
IPS Inline
Leucite
1.1 Press-on metal
(17% to 25%)
IPS InLine POM
Injection-molded
Vita PM9
Figure 9.
Figure 8. Organizational chart of commercially available dental ceramics for all-ceramic restorations, based on the matrix composition, concentration and type of filler, the manufacturing process and trade
name. For polycrystalline ceramics not containing glass (3), the main phase (“matrix”) is alumina or zirconia, and “loads” are not particles; are modified atoms called “dopants or stabilizers.” Cerec, chair-
side, and inLab, for the dental technician, are types of CAD/CAM systems. Superscript numbers refer to the manufacturers: 1-Vita Zahnfabrik; 2-Ivoclar Vivadent; 3-Pentron; 4-Den-Mat; 5-Chameleon
Dental Products; 6-Nobel Biocare; and 7-Dentsply Prosthetics.
Figure 9. Organizational chart of commercially available dental glass ceramics for veneering of all-ceramic restorations, based on the matrix composition, concentration and type of filler, the manufacturing
process and trade name.
307
Independent of the indications suggested by the manufacturers, clinical studies pre-
GENERAL CLINICAL
RECCOMENDATIONS
sent other recommendations concerning the directions of current ceramic systems. Ce-
ramics with a high glass content, such as feldspar, are indicated for veneers of anterior
teeth, such as ceramic veneering as well as for partial restorations in posterior teeth with
restrictions, because these restorative materials do not exhibit the guaranteed sufficient
strength to withstand mechanical stresses without the support of the remaining tooth
structure,69 which for single crowns, restricts their use for veneering copings which are fa-
bricated from tough infrastructure ceramics. Leucite-reinforced ceramics are indicated for
veneers, veneering ceramics and partial restorations of the posterior teeth.59,41 Ceramics
based on lithium disilicate are recommended for single crowns and three-element fixed
bridges in anterior teeth as well as for posterior partial restorations.45,58,36,37,65,39,55,79,53,42
Alumina-reinforced (glass infiltrated) ceramics may be indicated for single crowns
and fixed bridges, with exception of In-Ceram Spinell, whose application is recommended
only for anterior teeth.75 Zirconia-reinforced (glass infiltrated) ceramics function well on sin-
gle crowns and three- element fixed bridges in the anterior segment. For the molar region,
evidence suggests that only polycrystalline ceramic systems are indicated, since zirconia
and alumina have superior mechanical properties as an infrastructure material and may
also be used in implant abutments and implant-supported restorations.59,51
The successful application of ceramic systems depends on the clinician’s ability to
properly select the material with respect to their mechanical properties, aesthetics and ce-
mentation. From the perspective of surface treatment for cementation, ceramics may be
divided into etchable (sensitive to attack from hydrofluoric acid) and non etchable (resistant
to etching with hydrofluoric acid). The optimization of clinical behavior, of etchable cerami-
cs combined with adhesive cementation is advisable.49,50,51 Etchable (silica-based) cera-
mics are more aesthetic, translucent and have lower fracture resistance when compared
to non etchable ceramics (rich in metal oxides).33 Figures 10 and 11 are adaptations from
the tables demonstrated by Hilgert et al.,45 organize the main ceramic systems according
to the type of surface treatment required for cementation.
Ceramics that contain high amounts of metal oxides (> 85%), such as alumina or
zirconia, are not sensitive to hydrofluoric acid, nor are their surfaces rich in silica. Thus,
the adhesive cementation through etching and silanization does not generate acceptable
results. Non etchable ceramics are mainly characterized by their high strength compared
to silica-based ceramics, as a result, the indication for ceramic materials not sensitive
to hydrofluoric acid is for the preparation of infrastructures of crowns and fixed bridges,
which will be veneered by feldspathic and glass-ceramics. The high strength allows that
the ceramic for infrastructures not to depend on the support given by the dental substrate
via adhesive bonding, to resist the occlusal efforts. This means that by the existence of
a preparation geometry favorable to macromechanical retention, is possible to perform
cementation by the conventional technique.75 If there is a need or professional preferen-
ce for the adhesive cementation in non-etchable all-ceramic restorations, It is necessary
to treat the internal surface of the restorations in order to promote surface irregularities,
as hydrofluoric acid promotes as a surface treatment of etchable ceramics. Accordingly,
some surface treatment techniques have been deemed to be satisfactory: silica coating
308
CERAMIC SYSTEMS INDICATIONS CHARACTERISTICS
Leucite-reinforced glass ceramics
IPS Empress (Ivoclar Vivadent) lnlays, Onlays, Overlays, Crowns, Veneers Injection processing under heat and pressure
Fracture strength = 160MPa
Leucite-reinforced glass ceramics

IPS Empress CAD (Ivoclar Vivadent) lnlays, Onlays, Overlays, Crowns, Veneers CAD/CAM Processing
Fracture strength = 16DMPa
Feldspathic ceramics.
VITABLOCS (VITA) lnlays, Onlays, Overlays, Crowns, Veneers CAD/CAM Processing
Fracture strength = 15DMPa
Crowns and Veneers (Anatomical Lithium disilicate-reinforced glass-ceramics

E-Max (Ivoclar Vivadent) restorations or copings). Infrastructure for Injection processing under heat and pressure
anterior fixed bridges of up to three elements. Fracture strength = 36DMPa
Crowns and Veneers (Anatomical Lithium disilicate-reinforced glass-ceramics

E-Max CAD (Ivoclar Vivadent) restorations or copings). Infrastructure for CAD/CAM Processing
anterior fixed bridges of up to three elements. Fracture strength = 36DMPa
Restorations made by the refractory die

Veneers, lnlays and Onlays with
Feldspathic Ceramics technique
restrictions due to low resistance
Fracture strength = 90 to 1 00MPa
Figure 10.
CERAMIC SYSTEMS INDICATIONS CHARACTERISTICS

Processing by slip casting or CAD / CAM followed
InCeram Spinell (VITA) Copings of Anterior Crowns by glass infiltration
Fracture strength = 4DDMPa
Copings of anterior and posterior crowns; Processing by slip casting or CAD / CAM followed
InCeram Alumina (VITA) infrastructure of anterior and posterior by glass infiltration
fixed bridges of up to three elements Fracture strength = 5DDMPa
Copings of anterior and posterior crowns;

Densely sintered CAD / CAM processing
InCeram AL (VITA) infrastructure of anterior and posterior
Fracture strength >5DDMPa
fixed bridges of up to three elements
Copings of anterior and posterior crowns; Processing by slip casting or CAD / CAM followed
InCeram Zirconia (VITA) infrastructure of anterior and posterior by glass infiltration
fixed bridges of up to three elements Fracture strength = 6DDMPa

InCeram YZ (VITA) infrastructure of anterior and posterior
fixed bridges

Precera Alumina (Nobel Biocare) infrastructure of anterior and posterior
fixed bridges of up to four elements

Procera Zirconia (Nobel Biocare) infrastructure of anterior and posterior
Fracture strength = 1,2DDMPa
fixed bridges

ZirCAD (Ivoclar Vivadente) infrastructure of anterior and posterior
fixed bridges

LAVA (3M ESPE) infrastructure of anterior and posterior
Fracture strength >1,1DDMPa
fixed bridges

Cercon (Degudent) infrastructure of anterior and posterior
fixed bridges
Figure 11.
Figure 10. Main contemporary etchable ceramic systems, indications and characteristics (FS - flexural strength, information provided by the manufacturers).
Figure 11. Some of the main non-etchable contemporary ceramic systems, indications and characteristics (FS - flexural strength, information provided by the manufacturers).
309
and silanization, sandblasting with aluminum oxide and use of special primers (10-MDP
monomer), sandblasting with aluminum oxide and use of special cements (10-MDP mo-
nomer) and, finally, an association between silica coating, silanization and application of
primers or special cements (both with 10-MDP monomer). However, for the long-term,
only the association of sandblasting with aluminum oxide and resin cements promotes the
most stable bond strengths.75,9
When it comes to promoting increased longevity to anterior ceramic restorations, the
DECISION-MAKING:
CERAMIC CROWNS OR
VENEERS?
clinician should be aware of the factors related to the patient, the quality of the remaining
dental tissue and the ceramic system which is the most appropriate for each individual
situation.59,16,19
THE PATIENT
Several factors associated with the patient may influence the survival rate of veneers
and anterior crowns. As with any restorative procedure, patients exhibiting a high risk of
caries do not respond well to treatment because of the high incidence of secondary ca-
ries, especially if the margins of the preparations are located in dentin.52,68 Therefore, for
these patients, any attempt to restore the anterior teeth should only be considered if mo-
nitoring and prevention measures have been established beforehand, if not the restorative
healing treatment in these patients should be discouraged.87
The patient’s age makes a difference. The longevity of all-ceramic restorations may
be impaired in individuals above 60 years of age.12 These patients may have occlusal
overloading due to a lack of posterior tooth support and reduced salivary flow as a result
of drug use and periodontal problems. Ceramic restorations may still exhibit poor perfor-
mance in the elderly due to less or the absence of cervical enamel, it has gradually been
worn with aging. Still, by the fact that root dentin exposure is common in such patients,
the margins of the preparations are generally in dentin, which are more susceptible to
microleakage.78,77,32,87 The above factors make elderly patients difficult to treat with anterior
ceramic restorations. Extra attention and close monitoring of these patients should be per-
formed, and patients should follow the clinical recommendations for better performance
of the restorations.
THE REMAINING DENTAL TISSUE

The evaluation of the quantity and quality of the remaining dental tissue modulates
the choice between crowns and ceramic veneers on anterior teeth. In developing the
treatment planning, the clinician should determine whether the tooth is vital or endodon-
tically treated. In the second case, the need for intracanal post cementation must be
evaluated and the clinician must bear in mind that a minimum of 1,0 mm of dentin such
as circumferentially localized must be maintained.83 The presence of a darkened substrate
is common for endodontically treated teeth, therefore, generally a reduction of about 2.0
310
mm is required to eliminate the chromatic influence of the preparation, giving the ceramist
the possibility of creating room for a ceramic restoration with excellent aesthetic characte-
ristics.15,64 Ceramic crowns are better restorative solutions than veneers for endodontically
treated teeth19,15,64 because crowns provide increased strength, greater retention, better
aesthetics and increased longevity, compared to ceramic veneers in this case. However,
it should be considered that often the stability of a non-vital tooth is reduced due to the
amount of structure removed during preparation.59,51
Ceramic veneers should be indicated only when bonding is totally viable. This signi-
fies that the greater the amount of enamel, the better is the adhesion. The preparation for
this restorative modality should primarily be confined to enamel, or display 70% of enamel,
especially at the margins of the preparation.14,41 Complete cementation failures which cau-
se debonding of the ceramic veneers have been reported in preparations exhibiting 80%
of its area in dentin. These failures are unlikely to occur when a minimum of 0.5 mm of
enamel is peripherally present.80,19,67
In this sense, to prevent microleakage events and secondary caries, it is essential
that the margins of preparation are in enamel and free of composite,78,38 because partial
adhesion to dentin or composite and the presence of high occlusal loads during static
and dynamic occlusions increase the susceptibility of ceramic to fracture.78 Therefore, the
ceramic crowns should be chosen in detriment to veneers if dentin is the primary substrate
for bonding to a dental preparation, or in its margins, and also if there are extensive resto-
rations such as class IV and III, the dimensions of which exceed the edge of the cervical
enamel of the preparation.
THE CERAMIC SYSTEM

In a recent literature review carried out by Della Bona & Kelly,23 it was concluded that,
for crowns and veneers, the clinician may choose any modern ceramic system. However,
the choice of the ceramic system is highly dependent on the type of restoration (crowns
or veneers), the type of cementation (adhesive or traditional), function and aesthetic de-
mands of each case.
Ceramics are particularly ideal for veneers and should, where possible, be indicated
for additive reconstructions to restore lost enamel, ie without preparation. It is therefore
crucial that the ceramic allows for hydrofluoric acid surface treatment, followed by silani-
zation, in order to then be adhesively cemented.80,64 In addition, considering that aesthe-
tics is of great interest for the anterior teeth, a ceramic system for these teeth would be
relatively translucent, to allow the dental technician to build a chromatic expression inside
the ceramic. Leucite-reinforced ceramics and traditional feldspathic ceramics are the ma-
terials that best meet these prerequisites.59,84,64
With respect to all-ceramic crowns, a wider range of systems may be used. Etcha-
ble leucite reinforced ceramics and lithium disilicate reinforced ceramics are suitable for
cases where adhesive cementation is possible. Especially leucite-reinforced ceramics,
which offer good tooth-ceramic bond trength to provide longevity and aesthetics.59,20,63
Ceramic systems which may not be adhesively cemented (not etchable), such as alumina
and zirconia polycrystalline ceramics, are known as high-strength ceramics due to their
311
optimal mechanical properties and are important for patients with high functional and pa-
rafunctional occlusal loads. On the other hand, non etchable ceramics have low aesthetic
characteristics and are recommended as infrastructure materials.59,51 These systems, in
addition to the monolithic lithium disilicate crowns may be cemented with conventional
glass ionomer or zinc phosphate cements.77,67,66 A general summary of the implications of
crowns and ceramic veneers in anterior teeth is shown in Tables 1 and 2.
Table 1. Summary of the implications of crowns and ceramic veneers in anterior teeth ( - not recommended, + recommended).
ALL-CERAMIC CROWNS EXTENDED CERAMIC VENEERS
Removal of tooth structure − +
Restoration stability + −
Tooth stability − +
Risk of chromatic discrepancy + − / +*
due to tooth substrate
* If less translucent glass-ceramics were employed.
Table 2. Recommendations for the selection of all-ceramic crowns and extended veneers in anterior teeth.
ALL-CERAMIC CROWNS EXTENDED CERAMIC VENEERS-
.
Preparation margin localized in +
dentin . -
Non-vital teeth + -
.
Presence of extensive +
restorations . +
.
Presence of broad −
.
area of enamel also .
on the preparation margin . − / +*
Discolored teeth +
* Use glass-ceramics with high capacity of substrate masking.
Ceramics have played an important role in restorative dentistry and are the best
CONCLUSIONS
materials to reproduce the aesthetic features of natural teeth. Advances related to their
mechanical properties have been crucial to the universalization of their use. However, due
to the great variability of available systems achieving clinical success, the professional
must have a high level of awareness of the scientific evidence in order to properly choose
the ceramic system, as much for optimizing the aesthetic result as well as for structural
longevity of the restorative procedure.
312
1. Abduo J, Lyons K, Swain M. Fit of zirconia fixed partial denture: a systematic review. J Oral Rehab. 2010;47:866-76.
REFERENCES
2. Alghazali N, Laukner J, Burnside G, et al. An investigation into the effect of try-in pastes, uncured and cured resin cements on the
overall color of ceramic veneer restorations: an in vitro study. J Dent. 2010;38(Suppl 2):e78-86.
3. Andersson M, Oden A. A new all-ceramic crown: a dense-sintered, high purity alumina coping with porcelain. Acta Odontol Scand.
1993;51:59-64.
4. Atsu SS, Aka PS, Kucukesmen HC, et al. Age-related changes in tooth enamel as measured by electron microscopy: implications
for porcelain laminate veneers. J Prosthet Dent. 2005;94(4):336-41.
5. Barghi N, Berry TG. Post-bonding crack formation in porcelain veneers. J Esthet Dent. 1997;9:51-4.
6. Belli R, Guimaraes JC, Filho AM, Vieira LC. Post-etching cleaning and resin/ceramic bonding: microtensile bond strength and EDX
analysis. J Adhes Dent. 2010 Aug;12(4):295-303.
7. Belli R, Guimaraes JC, Lohbauer U, Baratieri LN. On the brittleness of dental ceramics: why do they fail? Quintessence Dent Tech.
2010;33:152-62.
8. Birmann MB. Cerâmica: arte da terra. São Paulo: Callis; 1987.
9. Blatz MB, Sadan A, Kern M. Resin-ceramic bonding: a review of the literature. J Prosthet Dent. 2003 Mar;89(3): 268-74.
10. Bottino MA, et al. Bonding of Y-TZP to dentin: effects of Y-TZP surface conditioning, resin cement type, and aging. Oper Dent. 2014
May;39(3):291-300.
11. Breschi L, Mazzoni A, Ruggeri A, Cadenaro M, Di Lenarda R, Dorigo EDS. Dental adhesion review: aging and stability of the bonded
interface. Dent Mater. 2008;24(1):90-101.
12. Burke FJT, Lucarotti PSK. Ten-year outcome of porcelain laminate veneers placed within the general dental services in England and
Wales. J Dent. 2009;37(1):31-8.
13. Chai J, Takahashi Y, Sulaiman F, Chong K, Lautenschlager EP. Probability of fracture of all-ceramic crowns. Int J Prosthodont.
2000;13:420-4.
14. Chang JC, Hart DA, Estey AW, Chan JT. Tensile bond strengths of five luting agents to two CAD-CAM restorative materials and
enamel. J Prosthet Dent. 2003;90:18-23.
15. Cheung W. A review of the management of endodontically treated teeth: post, core and the final restoration. J Am Dent Assoc.
2005;136(5):611-9.
16. Christensen GJ. Are veneers conservative treatment? J Am Dent Assoc. 2006;137(12):1721-3.
17. Christensen GJ. Facing the challenges of ceramic veneers. J Am Dent Assoc. 2006;137(5):661-4.
18. Christensen GJ. Longevity versus esthetics: the great restorative debate. J Am Dent Assoc. 2007;138(7):1013-5.
19. Christensen GJ. Veneer mania. J Am Dent Assoc. 2006;137(8):1161-3.
20. Conrad HJ, Seong WJ, Pesun IJ. Current ceramic materials and systems with clinical recommendations: a systematic review. J
Prosthet Dent. 2007;98(5):389-404.
21. De Munck J, Van Meerbeek B, Yoshida Y, Inoue S, Vargas M, Suzuki. K, et al. Four-year water degradation of total-etching adhesives
bonded to dentin. J Dent Res. 2003;82(2):136-40.
22. De Souza G, Hennig D, Aggarwal A, Tam LE. The use of MDP-based materials for bonding to zirconia. J Prosthet Dent. 2014
Oct;112(4):895-902.
23. Della Bona A, Kelly JR. The clinical success of all-ceramic restorations. J Am Dent Assoc. 2008;139 Suppl:8S-13S.
24. Della Bona A, Mecholsky JJ, Anusavice KJ. Fracture behavior of lithia dissilicate and leucite-based ceramics. Dent Mater. 2004;
20(10):956-62.
25. Della Bona A. Restaurações em cerâmica pura. Clínica - Int J Braz Dent. 2009;5(3):328-32.
26. Donovan TE. Factors essential for successful all-ceramic restorations. J Am Dent Assoc. 2008;139 Suppl:14S-8S.
27. Dumfarht H, Schaffer H. Porcelain laminate veneers: a restrospective evaluation after 1 to 10 years of service. Part II: Clinical results.
Int J Prosthodont. 2000;13:9-18.
28. Edelhoff D, Brix O. All-ceramic restorations in different indications: a case series. J Am Dent Assoc. 2011;142(4 suppl):1S-6S.
29. Edelhoff D, Güth JF, Lungwirth F, Fischer H, et al. Light transmission through lithium-disilicate ceramics with different levels of trans-
lucency. 45th Meeting IADR Barcelona 2010, J Dent Res. 2010;89: Special Issue B Abstract # 3660.
30. Elderton RJ. Clinical studies concerning re-restoration of teeth. Adv Dent Res. 1990;4:4-9.
31. Etman MK, Woolford MJ. Three-year clinical evaluation of two ceramic crown systems: a preliminary study. J Prosthet Dent. 2010;
103(2):80-90.
32. Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc. 2000;131(7):887-99.
33. Filho AM, Vieira LC, Araújo E, Monteiro Junior S. Effect of different ceramic surface treatments on resin microtensile bond strength.
J Prosthodont. 2004;13(1):28-35.
34. Fradeani M, Redemagni M, Conrado M. Porcelain laminate veneers: 6-to 12-year clinical evaluation: a retrospective study. Int J
Periodontics Restorative Dent. 2005;25:9-17.
35. Fradeani M, Redemagni M. An 11-year clinical evaluation of leucite-reinforced glass-ceramic crowns: a retrospective study. Quin-
tessence Int. 2002;33(7):503-10.
36. Frankenberger R, Reinelt C, Petschelt A, Krämer N. Operator vs. material influence on clinical outcome of bonded ceramic inlays.
Dent Mater. 2009;25(8):960-8.
37. Frankenberger R, Taschner M, Gárcia-Godoy F, Petschelt A, Krämer N. Leucite-reinforcerd glass ceramic inlays and onlays after 12
years. J Adhes Dent. 2008;10(5):393-8.
38. Friedman MJ. A 15-year review of porcelain veneer failure: a clinician’s observations. Compend Contin Educ Dent. 1998;19:625-30.
39. Galiatsatos AA, Bergou D. Six-year clinical evaluation of ceramic inlays and onlays. Quintessence Int. 2008;39(5):407-12.
40. Garvie RC, Hannink RH, Pascoe RT. Ceramic steel? Nature. 1975;258:703-4.
41. Garvie RC, Nicholson PS. Phase analysis in zirconia systems. J Am Ceram Soc. 1972;55:303-5.
42. Guess PC, Stappert CFJ, Strub JR. [Preliminary clinical results of a prospective study of IPS e.max Press- and Cerec ProCad-partial
coverage crowns]. Schwelz Monatsschr Zahnmed. 2006;116(5):493-500.
43. Guess PC, Stappert CFJ. Midterm results of a 5-year prospective clinical investigation of extended ceramic veneers. Dent Mater.
2008;24(6):804-13.
44. Haselton DR, Diaz-Arnold AM, Hillis SL. Clinical assessment of high-strength all-ceramic crowns. J Prosthet Dent.
2000;83:396-401.
313
45. Hilgert LA, Monteiro Jr. S, Vieira LCC, Gernet W, Edelhoff D. A escolha do agente cimentante para restaurações cerâmicas. Clínica
- Int J Braz Dent. 2009;5(2):194-205.
46. Horn HR. Porcelain laminate veneers bonded to etched enamel. Dent Clin North Am. 1983;27(4):671-84.
47. Johnson GH, Craig RG. Accuracy of addition silicones as a function of technique. J Prosthet Dent. 1986; 55:197-203.
48. Jr C. Etched porcelain facial veneers: a new treatment modality based on scientific and clinical evidence. N Y J Dent. 1983;53(6):255-9.
49. Kelly JR. Dental ceramics: current thinking and trends. Dent Clin North Am. 2004;48(2):viii,513-30.
50. Kelly JR. Dental ceramics: what is this stuff anyway? J Am Dent Assoc. 2008;139 Suppl:4S-7S.
51. Kelly J, Benetti P. Ceramic materials in dentistry: historical evolution and current practice. Aust Dent J. 2011;56:84-96.
52. Kidd EAM, Fejerskov O. What constitutes dental caries? Histopathology of carious enamel and dentin related to the action of cario-
genic biofilms. J Dent Res. 2004;83(Spec Iss C):35-8.
53. Krämer N, Ebert J, Petschelt A, Frankenberger R. Ceramic inlays bonded with two adhesives after 4 years. Dent Mater. 2006;22(1):
13-21.
54. Krämer N, Frankenberger R. Clinical performance of bonded leucite-reinforced glass ceramic inlays and onlays after eight years.
Dent Mater. 2005;21(3):262-71.
55. Krämer N, Taschner M, Lohbauer U, Petschelt A, Frankenberger R. Totally bonded ceramic inlays and onlays after eight years. J
Adhes Dent. 2008;10(4):307-14.
56. Kunii J, Hotta Y, Tamaki Y, Ozawa A, Kobayashi Y, Fujishima A, et al. Effect of shrinkage on the marginal and internal fit of CAD/
CAM-fabricated zirconia frameworks. Dent Mater. 2007;26(6):820-6.
57. Land CH. Porcelain dental art. Dent Cosmos. 1903;65:615-20.
58. Lange RT, Pfeiffer P. Clinical evaluation of ceramic inlays compared to composite restorations. Oper Dent. 2009;34(3):263-72.
59. Magne P, Douglas WH. Cumulative effects of successive restorative effects on anterior crown flexure: intact versus veneered inci-
sors. Quintessence Int. 2000;31:5-18.
60. Magne P, Magne M, Belser U. The esthetic width in fixed prosthodontics. J Prosthodont.1999;8(2):106-18.
61. Magne P, Versluis A, Douglas WH. Effect of luting composite shrinkage and thermal loads on the stress distribution in porcelain
laminate veneers. J Prosthet Dent. 1999;81:335-44.
62. Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental restorations over 14 years. Part II: Effect of thickness of Dicor
material and design of tooth preparation. J Prosthet Dent. 1999;81:662-7.
63. Mansour, YF, Al-Omiri MK, Khader YS, Al-Wahadni A. Clinical performance of IPS-Empress 2 ceramic crowns inserted by general
dental practitioners. J Contemp Dent Pract. 2008;9(4):9-16.
64. Meijering AC, Creugers NHJ, Roeters FJM, Mulder J. Survival of three types of veneer restorations in a clinical trial: a 2.5-year interim
evaluation. J Dent. 1998;26:563-8.
65. Naeselius K, Arnelund CF, Molin MK. Clinical evaluation of all-ceramic onlays: a 4-years restropective study. Int J Prosthodont. 2008;
21(1):40-4.
66. Ozkurt Z, Kazazoglu E. Clinical success of zirconia in dental applications. J Prosthodont. 2010;19(1):64-8.
67. Peumans M, De Munck J, Fieuws S, et al. A prospective ten-year clinical trial of porcelain veneers. J Adhes Dent. 2004;6:65-76.
68. Peumans M, Kanumili P, De Munck J, Van Landuyt K, Lambrechts P, Van Meerbeek B. Clinical effectiveness of contemporary adhe-
sives: a systematic review of current clinical trials. Dent Mater. 2005;21(9):864-81.
69. Raigrodski AJ. All-ceramic full-coverage restorations: concepts and guidelines for material selection. Pract Proced Aesthet Dent.
2005;17:249-56; quiz 258.
70. Raigrodski AJ. Contemporary all-ceramic fixed partial dentures: a review. Dent Clin North Am. 2004;48:531-44.
71. Reich SM, Wichmann M, Rinne H. Clinical performance of large, all-ceramic CAD/CAM-generated restorations after three years: a
pilot study. J Am Dent Assoc. 2004;135(5):605-12.
72. Rekow ED, Harsono M, Janal M, Thompsin VP, Zhang G. Factoerial analysis of variables influencing stress in all-ceramic crowns.
Dent Mater. 2006;22:125-32.
73. Rosenblum MA, Schulman A. A review of all-ceramic restorations. J Am Dent Assoc. 1997;128(3):297-307.
74. Rouse JS. Full veneer versus traditional veneer preparation: a discussion of interproximal extension. J Prosthet Dent. 1997;78(6):
545-9.
75. Sadowsky SJ. An overview of treatment considerations for aesthetic restorations: a review of the literature. J Prosthet Dent. 2006;
96(6):433-42.
76. Scotti R, Cardelli P, Baldissara P, Monaco C. Clinical fitting of CAD/CAM zirconia single crowns generated from digital intraoral im-
pressions based on active wavefront sampling. J Dent. 2011 Oct 17.
77. Shahverdi S, Canay S, Sahin E, Bilge A. Effects of different surface treatment methods on the bond strength of composite resin to
porcelain. J Oral Rehabil. 1998;25(9):699-705.
78. Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior dental aesthetics. J Am Dent Assoc. 2006;137(2):
160-9.
79. Stoll R, Cappel I, Jablonski-Momeni, Pieper K, Stachniss V. Survival of inlays and partial crowns made of made of IPS Empress after
10-year observation period and in relation to various treatment parameters. Oper Dent. 2007;32(6):556-63.
80. Suputtamongkol K, Anusavice KJ, Suchatlampong P, et al. Clinical performance and wear characteristics of veneered lithia-disilica-
te-based ceramic crowns. Dent Mater. 2008;24(5):667-73.
81. Suttor D, Bunke K, Hoescheller S, Hauptmann H, Hertlein G. LAVA: the system for all-ceramic ZrO2 crown and bridge frameworks.
Int Comput Dent. 2001;4:195-206.
82. Tay FR, Pashley DH, Suh BI, Carvalho RM, Itthagarum A. Single-step adhesives are permeable membranes. J Dent. 2002;30(7-8):
371-82.
83. Tay FR, Pashley DH. Resin bonding to cervical sclerotic dentin: a review. J Dent. 2004;32(3):73-96.
84. Toksavul S, Toman M. A short-term clinical evaluation of IPS Empress 2 crowns. Int J Prosthodont. 2007;20:168-72.
85. Van Noort, R. Introdução aos materiais dentários. 2a ed. Porto Alegre: Artmed; 2004.
86. Weinstein M, Katz S, Weinstein AB. Fused porcelain-to-metal teeth. U.S. Patent no. 3,052,982, Sept. 1962. Washinton, D.C.: U.S.
Patent Office.
87. Yoshiyama M, Tay FR, Doi J, Nishitani Y, Yamada T, Itou K, et al. Bonding of self-etching and total-etching adhesives to carious
dentin. J Dent Res. 2002;81(8):556-60.
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315
chapter 8
impression taking for ceramic veneers
the essence of communication
Renata Gondo Machado | Rafael de Almeida Decurcio | Lúcio Monteiro
When fabricating ceramic restorations, the transference of clinical information is es-
INTRODUCTION
sential to the ceramist. The rehabilitation planning and photographic protocol are key ele-
ments linking this communication between professionals, the design of the preparation,
the anatomy of adjacent teeth and the architecture of the periodontal tissues need to be
replicated in detail, to enable the ceramist conditions for the implementation of their work
to be accurate without questions or improvisations. Therefore, accuracy during the im-
pressioning procedure is all to essential.
The impression consists of a printing step with a specific material, which results in
obtaining a mold, from which a model is prepared with a faithful copy of the teeth and
adjacent structures of interest. Often this decisive step is neglected, carried out in a rush,
in the final moments of a heavy consultation. As well as planning, preparation and cemen-
tation, the impression should be performed during a specific appointment, so that the
professional and the patient may reach a satisfactory outcome.
The professional must have scientific knowledge for the proper selection of materials
and the correct execution of the technique, in addition to skill and access to specific tools.
The purpose of this chapter is to guide the professional about the material choice
and the step by step on how to carry out an impression, easily and effectively for predic-
table results in the production of ceramic veneers.
The first step towards a high-quality impression is the proper material selection.1
IMPRESSION
MATERIAL
Various types of impression materials are available on the market. The most suitable
for ceramic veneers are polyvinylsiloxane-based elastomers, better known as addition-
-reaction silicones (or PVS), because of their excellent physical properties (Table 1). The
name of the material stems from the chemical reaction by addition of silane and hydrogen
groups, through vinyl double bonds.25 Since this reaction does not prsent any residual
polymerization, nor release volatile by-products causing shrinkage, the result is a material
with exceptional dimensional stability, which overrides all other available products. The-
refore, it allows for the production of several models obtained from a single impression,
with the same degree of precision.10 Ceramic veneers, contact lenses or fragment-type
restorations impose a requirement of exacting detail in the reproduction of the substrate
to be restored, because they do not allow for the minimal dimensional variations under
the risk of misadaptation and hence immediate failure to the aesthetic result as well as
reduced longevity. Long-term changes occur mainly from accelerated marginal leakage,
due to the inevitable degradation of thickened resin cement, and hence the promotion of
undesirable marginal staining.
Since they exhibit a low coefficient of permanent deformation and excellent elastic
recovery, the dimensional change after impression removal is virtually nonexistent.10
Another advantage is versatility and workability. In their commercial form, addition-
-reaction silicone is present in the form of a paste with different viscosities (high, medium,
low and ultra-low), due to the amount of filler in the composition, lending their usage to a
318
variety of techniques. This fact thus enables for the use of low viscosity materials (fluid)
to capture fine details, such as in the case of termination of the preparation, as well as
high viscosity materials (putty) as in the case of an individual tray, to help the infiltration of
the low viscosity material into the gingival sulcus. The lower the viscosity, the better the
reproduction of peculiarities; however, the greater will be the polymerization shrinkage.9 All
pastes of different consistencies, have a base paste and a catalyst paste promoting the
polymerization of the material. High-viscosity pastes are available in the form of tubes, dis-
pensed using spoons or in cartridges for automatic mixing electronic equipment. Regular,
light and ultra-light consistency pastes are found in cartridges in a self-mixing system. In
this system, the silicone is mixed with a tip with built-in spirals, positioned within a special
mixing gun dispenser. Thus, the material may be applied directly to the teeth and adja-
cent structures to be copied. These self-mixing systems guarantee superior proportioning,
longer working time, and a more homogeneous mix, with less incorporation of bubbles,
saving clinical time and material.
For the patient, the material is pleasant, without taste or unpleasant odor.
One disadvantage is the hydrophobicity of the material because of its chemical
structure. Due to this property, contact with moisture decreases the quality of the results.
To circumvent this inconvenience, surfactants have been added to some materials for
promoting hydrophilicity. Hence, there has been an improvement in its flow and compati-
bility with moisture, along with a reduction in the incorporation of bubbles during pouring.9
However, even turning the materials more hydrophilic, the presence of saliva and blood
also promote flaws. Therefore, moisture control is recommended throughout the impres-
sioning procedure with addition-reaction silicones.
On the market, there are excellent commercial products, such as Virtual (Ivoclar Vi-
vadent, Liechtenstein) and Elite HD (Zhermack, Italy) (Fig. 1 and 2).
Table 1. Main properties of elastomers.

PROPERTY ADDITION SILICONE CONDENSATION SILICONE POLIETHER
Detail reproduction excellent good excellent
Dimensional stability excellent regular very good
Elastic recovery excellent good good
Ease of removal moderate easy hard
Tear strength satisfactory satisfactory satisfactory
Setting time up to 6 minutes 8 minutes 6 minutes
Working time medium/long medium/long short/medium
Pouring time até 7-14 dias up to 1 hour up to 7 days
Shrinkage 0.05% 0.6% 0.15%
Cost very high regular very high
Hydrophobicity hydrophobic hydrophobic hydrophilic
Source: Adapted from Shillingburg & cols.,25 Baratieri & cols.,2,3 Pegoraro & cols.23 and Mesquita & cols.18
319
Figure 1. Virtual® (Ivoclar Vivadent, Liechtenstein).

Figure 2. Elite HD® (Zhermack, Italy).
After the setting of the impression material, the implementation of the technique
STEP-BY-STEP OF
IMPRESSION TAKING
must be meticulous. Remember, for a quality impression, a quality material is not enough.
Knowledge is what promotes technical expertise and the skill of a professional.
IMPRESSION TIMING
Without any shade of doubt, material and technique are critical. The quality of the
preparation and of the periodontium are also essential for positive results. A good impres-
sion demands cervical termination is at the appropriate gingival level without invasion of
the biologic width, sharp and polished, for thorough reproduction. The periodontal tissues
must be healthy. Inflamed gingiva presents edema and exudates, with frequent bleeding,
compromising the infiltration and polymerization reaction of the impression material. In
such cases, it is indicated to delay the procedure, and wait for the reestablishment of the
periodontium rather than carrying out tentatives in adverse conditions.23
Often, with the presence of bleeding, the professional makes use of haemostatic
agents. This practice is not recommended since their presence may adversely compro-
mise the reproduction of the cervical margin, due to the hydrophobic characteristic of the
impression material, as well as induce staining of the substrate to be restored, compromi-
sing the aesthetic result.
It is very important that the very moment of impression taking is performed without
being in a rush and in an organized manner.
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PROPHYLAXIS
In the case of procedures requiring provisional restorations, they must be carefully
removed to prevent any damage to the periodontium. It is recommended to clean the
dental surfaces with periodontal curettes and brushes (Microtuf®, Hot Spot Design), and
pumice, until all provisional cement remnants and plaque are removed, in such a manner
as to guarantee the best reproduction of the cervical termination.
TRAY SELECTION
The impression for the preparation of ceramics veneers, require that stock trays to be
utilized.4 According to the study by Cox & cols.,7 the more rigid the tray and the impression
material, the better the quality of the work model.
Partial plastic trays that allow for the simultaneous impression of the superior and in-
ferior arches and the occlusal registration, are suitable for the impression in specific cases
of a unitary preparation. Partial models must be attached to a functional partial articulator.
However, these trays are more flexible and therefore less resistant to deformation caused
by the weight of the stone during pouring, occurring distortions.8
With regard to ceramic veneers, as in the case presented in this chapter (Fig. 3-9), a
full-arch impression is recommended, because the greater the amount of contact betwe-
en the models, the more reliable and safe is its mounting in the articulator for the simulation
of the disocclusion guides and functional adjustments.9 It is imperative that the ceramist
has at their disposal all of the morphological nuances of the teeth within the arch and can
reproduce the appropriately desireable harmonious symmetry, even in the case of unitary
restorations. Thus, total rigid plastic stock or stainless steel trays are recommended (eg,
Morelli® or Maquira®) (Fig. 10). Due to the metallic malleability of aluminum trays, and their
possible promotion of considerable distortions in the impression, they are not indicated.
The tray must cover all the teeth in the anteroposterior and lateral direction, with
enough room for the impression material. The tray may not touch the teeth nor the pe-
riodontium or injure the patient. There is no need for customizing the tray with wax, due
to the consistency of the silicone, allowing for the displacement of material, may interfere
with the result.
A specific adhesive should be applied (eg, Universal Tray Adhesive®, Zhermack, Italy)
on the surface of the tray so that the impression material may adhere and thus contract in
the direction of the tray during polymerization, avoiding deformations. A thin layer of adhe-
sive is applied, 7 to 15 minutes before the impression procedure.
Proper tray selection prevents unexpected errors from occurring making the time of
impression taking comfortable and accurate. Neglecting this stage will result in a lack or
an excess of material, discomfort to the patient, lack of stability of the mold and/or rupture
in important sites.
321
Figure 3. Initial aspect of the face. Patient with complaints of aesthetic dissatisfaction due to gingival smile, length and visible shape of the teeth. (a) Right side view (b). Frontal view (c). Left side view.
Figure 4. Initial appearance of dental-lip relationships. (a) Note the discrete display of the incisal edges of the maxillary incisors with the lips slightly parted. (b) In the forced smile, one may see impairment
of the gingival aesthetics relationship and short clinical crowns.
Figure 5. Aspect of the smile 90 days after periodontal surgery for clinical crown lenghtening. (a) Note the the gingival dominance of the central incisors. (b) Notice the harmony of the lip-gingival relationship.
Figure 6. Preparation of the restorative trial (mock-up) by the indirect technique with bis-acrylic resin. (a) Insertion of composite resin along the incisal edge readjusting the incisal dominance. The
procedure is performed without an adhesive surface treatment. (b) Finishing and polishing of the trial.
322
Figure 10.
Figure 7. Appearance of the smile after the restorative trial. (a) Note the proper exposure of the incisal edges. (b) Smile after the restorative trial. Note the harmony between length and width of the teeth,
gingival contour and lips.
Figure 8. Removal of composite restorations. (a) Superficial removal of the composite resin restoration in tooth #12. (b) The removal of the restoration with a #12 scalpel blade is recommended to
prevent wear of enamel.
Figure 9. (a) Smoothing of the angles and finishing of the preparation. (b) Appearance of the teeth after removal of the restorations and elimination of the undercuts.
Figure 10. Selecting the tray.
323
GINGIVAL DISPLACEMENT
Cervical termination of the preparation and the emergence profile are critical areas to
be replicated in the working model for the manufacturing of ceramic veneers and contact
lenses. In the case of gingival or intrassulcular termination, gingival displacement needs
to be induced in order to allow for the access of the impression material into the sulcus.
There are several methods of gingival displacement:
• mechanical - displacement with impression copings or cords;
• chemo-mechanical - displacement with chemically-soaked cords;
• surgical; and
• ultrasonic.
The strategy we suggest is mechanical displacement by compression, with two
non-impregnated cords. In this technique, the gingival margin has a vertical clearance for
exposition of the tissue below the cervical preparation termination and a horizontal clearan-
ce towards the promotion of the proper thickness of the impression material.
Many professionals consider this stage as being complex because they are not able
to pack the cord and maintain it in the sulcus. This difficulty, most often occurs due to
inadequate cord choice, inadequate packing in the sulcus and the use of inappropriate
instruments. To select the ideal diameter of the cord, probing for determining the sulcus
depth and the gingival biotype should be performed. The larger the sulcus depth and
the thickness of attached gingiva, the greater the diameter of the indicated cord. If the
thickness of the attached gingiva is less than 1 mm, the inadequate displacement may
promote gingival recession.22,23
To control the moisture of the operative field and effective packing of the cords, it is
recommended to carry out relative isolation, with the use of a lip retractor, cotton rolls and
constant aspiration.
Initially, one cord of a smaller diameter and an adequate length should be packed
into the gingival sulcus, to encircle the entire buccal contour of the teeth to be restored.
Packing of the cord should be carried out carefully with the proper spatula (packing instru-
ment) (Fig.11), with light pressure for disruption of the junctional epithelium and irreversible
damage to the gingival tissue not to occur. This first cord is intended to control gingival
fluid moisture, to promote the vertical displacement and to limit the infiltration depth of the
impression material to avoid excessively thin material and consequent tearing. This cord
should be maintained inside the sulcus throughout the impression procedure (Fig. 12 and
13a).
Then, a continuous cord of greater diameter is packed from the distal aspect of the
most posterior tooth to be restored, on one side, to the distal aspect of the most poste-
rior tooth on the opposite side, contouring the papillae.This cord must be placed partially
deep, so that it is half exposed and half inside the sulcus so that it produces lateral displa-
cement of the gingival margin. Leave one end of the cord out of the sulcus to facilitate its
removal (Fig. 13b and 14).
After positioning the cords, one should wait at least 5 minutes for the displacement
of the gingival tissue to occur. Saliva control is required during the entire procedure for the
gingival manipulation to be effective.
324
Figure 11. Cord-packing Instrument.

Figure 12. Gingival displacement. (a) Packing the first cord of a smaller diameter. (b) Notice the position of the cord packing instrument. (c) First cord positioned.
Figure 13.Gingival displacement. (a) Aspect of packing the first cord from molar to molar (b) Packing the second cord
Figure 14. Second cord packed (a) Buccal view. Note that the cord should be partially packed into the sulcus. (b) Incisal view.
325
IMPRESSION TAKING
The principle of impression taking using the addition-reaction silicones consists of
performing an imprint with a high-viscosity paste that promotes displacement of the tissue,
and a low viscosity paste, which promotes the reproduction of the fine details. For this to
occur, the impression may be performed in several ways. The technique influences the
accuracy as well as the dimensional stability of the impression.16
The most common techniques of using materials of different viscosities are:
• two-step impression; and
• one-step impression.
Two-step impression
This technique is also known as:
• double impression;
• two-time impression;
• wash-out technique; or
• relief technique.
The basis of the technique is to carry out a preliminary high-viscosity silicone im-
pression, in the fabrication of a custom tray, followed by washing-out with a low viscosity
silicone. This is the preferred procedure for the impression of preparations of multiple
veneers and for contact lenses. The advantage is that the professional may perform the
entire procedure with greater working time along with patient comfort. What is more, there
is greater control over the application and distribution of the material.
The first step should be the organization of the clinical desk with the following ma-
terials:
• tweezers, periodontal probe and dental mirror;
• lip retractor;
• previously selected trays;
• addition-reaction silicone - high and low viscosity pastes;
• dosing spoons;
• polyvinyl film (PVC);
• dispensing gun for the low viscosity paste;
• mixing and dispensing tips; and
• adhesive for vinyl polysiloxane.
The high viscosity material should be dispensed and manipulated for the first impres-
sion. In this system, the base and catalyst pastes are dispensed by volume, with an equal
number of dosing spoons. As long as the proportions are respected, any formation of
byproducts from the reaction will be avoided, ie, without dimensional changes and without
compromise during pouring. Altered proportions negatively influence the final properties.
Mixing of the masses must be performed manually without gloves and with well
cleansed hands. Due to the fact that the sulfur from the latex gloves and talcum powder
reacts with the chloroplatinic acid activator and inhibits the polymerization reaction. The cli-
326
nician should also avoid touching the preparations and the gingival tissue with latex gloves
because it may also compromise the setting reaction. Often this change is not perceptible
in the impression, only after pouring, into the model. To overcome this situation, in cases
of tooth substrate contamination by the glove, cleansing with pumice is recommended.9
Using a rubber dam for absolute isolation may also contaminate the tooth substrate with
sulfur and damage the impression. If the wish is to use gloves, the professional should
opt for vinyl.
Manipulation should be carried out “squeezing” the base and catalyst pastes be-
tween the fingers and hands, dynamically and quickly, to obtain a homogeneous mass
without streaks. Check the working time for the material to be manipulated and inserted
into the tray before offering compression resistance, otherwise it may cause strain during
placement in the mouth, leading to distortions in the final impression.
The high viscosity silicone may also be commercially presented in cartridges for
self-mixing in an electronic device. In this system, the base and catalyst pastes are dis-
pensed and automatically mixed, allowing for a faster protocol and more uniform material
with lower incorporation of bubbles and risk of contamination.19 In addition it increases the
working time,9 but requires a costly investment.
After applying the adhesive for the silicone, the tray should be partially filled with the
material. Excess putty material complicates the placement and the flow of the material.
After filling, the positioning of a thin sheet of polyvinyl (PVC) over the surface of the high-vis-
cosity silicone is recommended, in order to serve as a spacer between the putty material
and the tooth, creating space for the wash-out of the low-viscosity material (Fig. 15a). In
this manner, the need for subsequent relief of the impression is eliminated. The tray must
be maintained in position for at least 4 minutes in accordance with the setting time recom-
mended by the manufacturer.
After removing the impression, the polyvinyl film should be removed, the try-in of the
filled tray is recommended to try the insertion axis and to verify the adaptation. In cases
of seating difficulties, the remaining excess and retentions should be properly removed to
ensure the uniform thickness of the low-viscosity vinyl polysiloxane paste.
If the polyvinyl film is not used, the relief of the impression should be performed with
sharp instruments, trimming undercuts (interdental space, occlusal surface, gingiva and
retentive edges), to ensure adequate and uniform thickness of the low-viscosity paste
without pressure to the structures. Ideally, this relief will allow for for a material thickness
of at most 2 mm.6 Greater reliefs are inadequate because there will be greater volume
shrinkage of the low viscosity material, which results in dimensional changes.20 The relief
technique through trimming is more complex due to the difficulty of controlling the amount
of material removed. Furthermore, an inadequate relief may create an occlusal step on the
adjacent teeth.5
As a result, relative isolation of the operative field and procedures for gingival displa-
cement should be performed, as previously described.
For impression with low viscosity silicone, an approximate 10 minute wait with the
cords in position for subsequent removal of the second cord of a greater diameter is
necessary. Excess moisture should be removed with compressed air. Avoid wetting the
327
entire operative field. Remember that moisture may compromise the impression in cases with hydrophobic material.
Simultaneously with the removal of the second cord, the low-viscosity silicone should be inserted into the gingival
sulcus over the first cord, throughout the extension of the cervical margin. For this, the cartridge with the base and catalyst
pastes should be adapted to utilize a dispensing gun and the mixing and application tip properly positioned (Fig. 15b).
After application of the pastes in the sulcus, a gentle air jet should be applied to ensure infiltration of the material (Fig. 16a).
Care should be taken since excess air may promote the incorporation of bubbles. The low viscosity paste should cover the
entire tooth, not only the cervical margins. The tray with high-viscosity paste should also be filled with low viscosity silicone,
which ensures greater uniformity in the distribution of the paste. Professionals should exercise caution and control over the
operative field, removal of the low viscosity paste by movement of the lips and tongue may occur during the placement of
the tray.
The assembly of high and low viscosity pastes into the tray must be brought into position. Great care must be taken
in repositioning the tray within the patient’s mouth. Inadequate pressure may dislodge the low viscosity material, and pro-
mote an unsatisfactory impression.5 To remove the impression, one should wait a minimum of 5 minutes (Fig. 16b). Not
complying with the setting time of the material can produce an impression with a rough and uneven surface.
Figure 15. Impression taking (a) Imprint with high viscosity silicone. Note that a polyvinyl film was used for the relief and as a spacer for the low-viscosity material. (b) Application of the low viscosity
silicone on the surface of the teeth. Note that the material should be applied, first, along the cervical margin.
Figure 16. Impression (a) After the application of the the low viscosity paste across all tooth surfaces, an air blast for improved infiltration and product distribution should be carried out. (b) Final
impression. Notice that the first cord, which was kept in the sulcus during impression taking was removed with the mold, ensuring an appropriate copy of the cervical termination.
328
One-step impression
In this technique, the impression is performed with high and low viscosity silicon, simulta-
neously. The procedure is simpler, faster and more comfortable for the patient. The advantage
is the reduction of clinical time and material savings. However, the working time is shorter and
there is the necessity of having a second person to carry out the manipulation of material.27 The
professional should be concentrated and organized because there are several critical steps being
performed at the same time.The application of the low viscosity material should be rapid, due to
the fact that the previously manipulated high viscosity material is being polymerized. In the case of
delay, the development of the elastic properties will start before the positioning within the mouth,
as well as the resistance produced by the onset from polymerization of the high-viscosity paste
may compromise the reproduction of tissues. Also with regard to positioning, bubbles which may
occur due to excessive pressure as well as flow and rupture of the impression. Another disadvan-
tage is the fact that the shrinkage of different viscosity materials takes place simultaneously ,which
dimensionally alters the working model.
Moreover, the reproduction of details may be accomplished by the high-viscosity paste, not
exclusively by the low viscosity paste. The putty material tends to “push” the low viscosity paste
off the preparation, so the critical areas, such as the cervical termination of the substrate to be
restored may end up being covered by the putty mass which does not precisely copy the details.5
Therefore, we opted for the two-step impression technique for restorative procedures with
ceramic veneers.
There is a great controversy about the ideal impression technique. For some authors, there
is no difference in the outcome,14,27 provided there is adequate gingival displacement.28 On the
other hand, there are authors who advocate the implementation of the one-step impression,17,21
mainly for single preparations.11 Other authors further argue that the two-step technique promo-
tes low dimensional variation compared to the one-step impression technique.5,10,20 Because the
details are recorded only by the low viscosity material,5 which compensates for the deformation
which may occur in the high-viscosity paste after removal from the mouth.6 Furthermore, since the
wash-out is carried out after the complete polymerization of the putty paste, any and all shrinkage
is restricted to the low viscosity paste, resulting in minimal dimensional change.5
The best choice must be made by the professional according to their working time and what
best adapts to each technique, although the authors do recommend the use of the two-step
technique.
REMOVAL OF THE IMPRESSION

The removal of the tray is a critical procedure which may compromise the accuracy of the
impression.27
Initially, it is recommended to break the seal at the bottom of the vestibule with air blasts,
which facilitates this procedure. The tray should never be removed through the use of undulating
or tilting movements, but in a single motion and as parallel as possible to the long axis of the teeth.
If the cord is removed together with the impression, this must be maintained, and the
pouring performed over the properly positioned cord. If it is dislocated within the impression, do
not try to carry out its repositioning. In this case, what would be the ideal would be to remove
the cord.
329
ANALYSIS OF THE IMPRESSION
A suitable impression is self-explanatory. When there is doubt, it means that the procedure should be reperformed.
It is preferable to repeat the execution of the impression rather than sending it to the technician only to discover that the
impression is unsuitable.
A suitable impression should present:
• a smooth and shiny appearance;
• sharp edges;
• the presence of a small amount of skirt material which has penetrated the gingival sulcus;
• absence of bubbles and irregularities in areas that could compromise the fabrication of the restoration;
• absence of visible areas of marked compression; and
• absence of interdental ruptures.
DISINFECTION OF THE IMPRESSION

The stone models obtained from contaminated impressions are capable of transmitting microorganisms to those who
manipulate them.26 Therefore, before being sent to the laboratory and / or poured, the impression must be properly rinsed
and disinfected in solution:
• 0.5% to 1% sodium hypochlorite; or
• 2% glutaraldehyde.
According to some authors,13 glutaraldehyde is the most effective bactericidal substance.
The impression must be sprayed with disinfectant spray and placed in a plastic container, hermetically sealed, for 10
minutes and then be rinsed with tap water. immersion of the impression in a disinfectant substance may also be carried
out, however soaking in a hypochlorite solution may have a corrosive effect on metal trays.
STORAGE OF THE IMPRESSION

Because of its dimensional stability, the impression may be stored for up to 14 days, provided that it is in a suitable
environment and not manipulated. Storage at temperatures above 25 ° C may promote a dimensional change.15
POURING
Due to the dimensional stability of the material and the absence of continuous polymerization,12 one can wait for 7
to 14 days for the pouring of the impression.1 The material may then be sent to the laboratory without the obligation of
pouring, this function is delegated to the ceramist who is responsible for the production of restorations. The impressions
should be sent along with the shade-matching information (Chapter 3), which includes the digital planning and photos with
the shade guide after preparation or the removal of resins. These photographs should be taken prior to the impression, so
that the dehydration of the teeth does not negatively interferes with the selection of the ceramic by the technician (Fig. 17).
One should wait at least 1 hour before the pouring of the impression, because some trademarks exhibit a secondary
reaction, which may lead to the formation of hydrogen gas as a byproduct from the polymerization. This release does not
promote dimensional change but may induce the formation of porosity in the stone model.12 The wait time for pouring is
also of great interest for the elastic recovery after removal from the mouth.
Interestingly, the ceramist fabricates at least two working models (Fig. 20): one model for making dies; and another
for the try-in of the restoration and reproduction of contact points and the emergence profile.
330
Figure 17. Shade selection Use of the shade guide and photography for communication with the ceramist.
Figure 18. Fabricating the provisional restoration. (a) Spot-etching on the teeth to be provisionally restored. (b) Application of the adhesive system.
Figure 19. Manufacturing of the provisional restoration. (a) Light curing of the adhesive system (b) Labial aspect of provisional restorations manufactured with composite resin.
Figure 20. Ceramic veneers fabricated. (a) Labial aspect. (b) Palatal aspect. The appropriate impression allows for the production of models identical to the oral conditions.
331
The production of a study model of an ideal quality requires knowledge, the proper selection of material and a method
for implementing the technique. The procedure is critical and very important towards the completion of the treatment (Fig.
21-26). Never neglect this step!
Figure 21. Aspect immediately after cementation.

Figure 22. Final appearance of the smile.
Figure 23. Final aspect. (a) Mouth slightly open presenting proper tooth exposure with lips at rest. (b) aspect of the smile. (c-d) Note the texturization of the ceramics, giving a natural look.
332
Figure 24a.
Figure 24b.
Figures 24-26. Final aspect.
333
Figure 26a.
334
Figure 26b.
335
Figure 26 c.
Figure 26 d.
336
1. Al-Zarea BK, Sughaireen MG. Comparative analysis of dimensional precision of different silicone impression materials. J
REFERENCES
Contemp Dent Pract. 2011;12(3):208-15.
2. Baratieri LN, et al. Odontologia restauradora: fundamentos & técnicas. São Paulo: Santos; 2010.
3. Baratieri LN, Monteiro Júnior S, Andrada MAC de, Vieira LCC, Ritter AV, Cardoso AC. Odontologia restauradora: fundamen-
tos e possibilidades. São Paulo: Santos; 2002.
4. Brosky ME. Laser digitalization of casts to determine the effect of tray selection and cast formation technique on accuracy.
J Prosthet Dent. 2002;87:204-9.
5. Caputi S, Varvara G. Dimensional accuracy of resultant casts made by a monophase, one-step and two-step, and a novel
two-step putty/light-body impression technique: an in vitro study. J Prosthet Dent. 2008;99(4):274-81.
6. Chaimattayompol N, Park D. A modified putty-wash vinyl polysiloxane impression technique for fixed prosthodontics. J
Prosthet Dent. 2007;98(6):483-5.
7. Cox JR, Brandt RL, Hughes HJ. A clinical pilot study of the dimensional accuracy of double-arch and complete-arch impres-
sions. J Prosthet Dent. 2002;87(5):510-5.
8. de Lima LM, Borges GA, Junior LH, Spohr AM. In vivo study of the accuracy of dual-arch impressions. J Int Oral Health.
2014;6(3):50-5.
9. Donovan TE, Chee WW. A review of contemporary impression materials and techniques. Dent Clin North Am. 2004;48(2):vi-
-vii, 445-70.
10. Dugal R, Railkar B, Musani S. Dimensional accuracy when making impressions is crucial to the quality of fixed prosthodontic
treatment, and the impression technique is a critical factor affecting this accuracy. J Int Oral Health. 2013;5(5):85-94.
11. Faria AC, Rodrigues RC, Macedo AP, Mattos Mda G, Ribeiro RF. Accuracy of stone casts obtained by different impression
materials. Braz Oral Res. 2008;22(4):293-8.
12. Garone Netto N, Burger RC. Inlay e onlay metálica e estética. São Paulo: Quintessence; 1998. cap. 5, p. 65-71.
13. Hiraguchi H, Kaketani M, Hirose H, Kikuchi H, Yoneyama T. Dimensional changes in stone casts resulting from long-term
immersion of addition-type silicone rubber impressions in disinfectant solutions. Dent Mater J. 2013;32(3):361-6.
14. Hung SH, Purk JH, Tira DE, Eick JD. Accuracy of one-step versus two-step putty wash addition silicone impression techni-
que. J Prosthet Dent. 1992;67(5):583-9.
15. Kambhampati S, Subhash V, Vijay C, Das A. Effect of temperature changes on the dimensional stability of elastomeric im-
pression materials. J Int Oral Health. 2014;6(1):12-9.
16. Levartovsky S, Zalis M, Pilo R, Harel N, Ganor Y, Brosh T. The effect of one-step vs. two-step impression techniques
on long-term accuracy and dimensional stability when the finish line is within the gingival sulcular area. J Prosthodont.
2014;23(2):124-33.
17. Luthardt RG, Walter MH, Quaas S, Koch R, Rudolph H. Comparison of the three-dimensional correctness of impression
techniques: a randomized controlled trial. Quintessence Int. 2010;41(10):845-53.
18. Mesquita E, Cé G, Thaddeu Filho M. Prótese unitária. Florianópolis: Ponto; 2008.
19. Nam J, Raigrodski AJ, Townsend J, Lepe X, Mancl LA. Assessment of preference of mixing techniques and duration of
mixing and tray loading for two viscosities of vinyl polysiloxane material. J Prosthet Dent. 2007;97(1):12-7.
20. Nissan J, Gross M, Shifman A, Assif D. Effect of wash bulk on the accuracy of polyvinyl siloxane putty-wash impressions. J
Oral Rehabil. 2002;29(4):357-61.
21. Pande NA, Parkhedkar RD. An evaluation of dimensional accuracy of one-step and two-step impression technique using
addition silicone impression material: an in vitro study. J Indian Prosthodont Soc. 2013;13(3):254-9.
22. Pegoraro LF, et al. Prótese fixa. São Paulo: Artes Médicas; 1998.
23. Pegoraro LF, et al. Bases para o planejamento em reabilitação oral. São Paulo: Artes Médicas; 2013.
24. Raigrodski AJ, Dogan S, Mancl LA, Heindl H. A clinical comparison of two vinyl polysiloxane impression materials using the
one-step technique. J Prosthet Dent. 2009;102(3):179-86.
25. Shillimburg Junior HT, Hobo S, Whitsett LD. Fundamentos de prótese fixa. Chicago: Quintessence; 1986.
26. Soares CR, Ueti M. Influence of different methods of chemical disinfection on the physical properties of type IV and V gypsum
dies. Pesqui Odontol Bras. 2001;15(4):334-40.
27. Vitti RP, da Silva MA, Consani RL, Sinhoreti MA. Dimensional accuracy of stone casts made from silicone-based impression
materials and three impression techniques. Braz Dent J. 2013;24(5):498-502.
28. Wöstmann B, Rehmann P, Trost D, Balkenhol M. Effect of different retraction and impression techniques on the marginal fit
of crowns. J Dent. 2008;36(7):508-12.
337
chapter 9
provisional restorations for ceramic veneers
Rafael Decurcio | Paula de Carvalho Cardoso | Luciano Reis Gonçalves | Fernanda Sakemi | Terence Romano
Apart from the obvious dissatisfaction of the patient, the absence of provisional res-
INTRODUCTION
torations in teeth prepared for ceramic veneers compromises pulp health, increases the
risk of caries on the surfaces of the prepared teeth and promotes gingival invagination over
the prosthetic preparations.11
A well adapted and polished provisional restoration allows for better control of plaque
and helps to maintain the gingival tissue healthy and with shape, position and an emer-
gence profile ideally suited for the installation of ceramic veneers.11 They are also essential
in maintaining the original tooth position when the preparation involves interproximal areas.
The provisional restorations are a reflection of the wax-up and mock-up, conse-
quently are key to increasing confidence between the patient and the professional, facilita-
ting each step related to the accomplishment of the ceramic veneers.5,12
In such cases of flaring, tooth crowding and the presence of restorations with oversi-
zed labial volume, it is impossible to fabricate the mock-up. In this situation, the provisional
plays an essential role towards the aaesthetic definition and communication with the cera-
mist, lending greater predictability to the final outcome.16 So, it is advisable that the patient
evaluates the results days after the insertion of the provisional, so that, if necessary, changes
may be carried out on the desired morphology, providing that they are within the limits of the
aaesthetic standards of reference. Further, as follows, an alginate impression is taken (Hy-
drogum 5, Zhermack, Italy) and sent to the ceramist, to be a reference of the length, width
and thickness of the ceramic veneers.
MATERIALS
AVAILABLE
Traditionally, the thermoplastic acrylic resin had been used as the material of choice
for the provisional; However, for ceramic veneers, the first choices are composite resin and
bisacryl, because of their improved mechanical and chromatic properties, as well as for
their ease of handling.7,15,27
To successfully meet the above requirements, materials for the fabrication of veneers
must have a number of ideal mechanical and physical properties, such as a high flexural
strength, wear resistance, fracture toughness and a high dimensional stability.13,16
Bis-acrylic resins were introduced into the market in order to supplement some fe-
atures of acrylic resins, such as ease of handling and the advantageous lower heating
produced throughout the polymerization process, eliminating aggressions to pulp1,25 and
soft tissues.
The availability of bis-acrylic resins in self-mixing cartridges has allowed for more
precise proportioning, in addition to having facilitated their use; at the same time, these
composites have enhanced working time for the professional. The organic resin compo-
sition, inorganic fillers and monomers provides them with the aaesthetic and properties of
strength similar to those of composites.23
However, bis-acrylic resins may present pigmentation from food or mouthrinses. In
this manner, changing the original shade of the provisional restoration may be the source
of an aaesthetic problem and result in patient dissatisfaction.9,20 The installation of provi-
340
sional restorations must be preceded by a very rigorous timing schedule with respect to
the ceramist, so that the interval between the provisional and the installation of the ceramic
veneers is as brief as possible.
Occasionally, mouthwashes with 0.12% chlorhexidine (Periogard®, Colgate, USA) are
used for chemical control of dental plaque, thus avoiding its accumulation in areas with atta-
ched temporaries where there is little or no access for toothbrushing and flossing.2,22,26 Howe-
ver, this mouthwash may affect the color stability of the provisional restorations and cause
further discoloration;8,24 a topic similar to that shown above, in which the time for completion
of the case must be carefully planned with the ceramist in charge.
One way to minimize this staining is through carrying out the polishing of the provisio-
nal bis-acrylic resin restorations after its instalation. Our Operative Dentistry team suggests
performing the polishing with less abrasive rubbers (Composite Technique Kit®, Shofu,
Japan) and zero pressure on the provisional under the risk of loss to its structure, consi-
dering the characteristic resilience of the material, and subsequent achievement of luster
with extra-fine diamond paste or pumice with felt wheels. Another possibility described in
the literature is the use of a glaze or polish coating (Biscover®, Bisco, USA), which reduces
formation of biofilm on provisional restorations, beyond the possibility of offering a brighter,
polished surface with color stability.6,14,23
Various techniques are described in the literature, including the indirect (laboratory) and
direct techniques.3,4,10,21 Despite favorable reports on the the use of high chromatic and phy-
sical performance acrylic resin (Alike®, GC, USA) for provisionalization of ceramic veneers17
(Figure 1), our Operative Dentistry Team has a part of its protocol the use of direct provisional
techniques, varying the restorative approach, in accordance with the material and the techn-
cal ability of the professional.
Figure 1.
Figure 1. Acrylic resin of high chromatic and physical performance (Alike®, GC, USA).
341
HANDS-FREE SCULPTURE WITH COMPOSITE RESIN (TABLE 1)
DIRECT
TEMPORARIES
A fast way for fabricating a direct provisional is the hands-free sculpture technique,
highly indicated for situations involving a few veneers. However, the technique is absolutely
dependent upon the professional skills of the dentist and therefore knowledge of tooth
morphology is essential for the restoration of tooth shapes, surface textures and the pro-
per inclination of the anterior teeth (Figure 4, Chapter 12).
The composite resin selected for this technique should be easy to manipulate (Be-
autifil II®, Shofu, Japan; Empress Direct®, Ivoclar Vivadent, Liechtenstein) the use of se-
veral types of composites to reproduce dentin, enamel and their effects (Figures 2 to 7).
Defining the type of composite resin will depend upon the thickness that the provisional is
required to restore. In cases where the thickness exceeds 1.2 mm the use of dentin resin
(0.3 mm average) and a subsequent insertion of resin enamel (0.8 mm average) is sug-
gested, dependent upon the involved third. Remember that all of the resin must initially be
layered in the cervical third and after which it is layered towards the middle and the incisal
thirds. Common errors such as graying have been observed when the sole use of enamel
resin in the fabrication of a provisional veneer thicker than 1.5 mm.
After selecting the desired composite and shade matching with the adjacent tooth
or to be copied (see Chapter 3), the substrate is spot-etched, rinsed and dried, followed
by an application of the adhesive system for further polymerization. Thereafter, a proper
amount of resin is inserted with a spatula (Sofia® spatula, Golgran, Brazil) (Figure 8a-d) over
the cervical region and the composite resin is accommodated with a brush soaked in a
special liquid (Modeling Resin®, Bisco, USA) throughout the entire labial surface (Figure
8e-f ).
Table 1. Comparison between the mock-up techniques.

. HANDS-FREE SCULPTURE WITH CLEAR MATRIX - COMPOSITE SILICONE MATRIX - BIS-ACRYL
. COMPOSITE RESIN RESIN RESIN
INDICATION A few teeth involving exclusively One or a few teeth exclusively Several teeth involving
. veneers involving veneers veneers and crowns
ABILITY TO SCULPTURE Fundamental Unnecessary Unnecessary
NECESSITY OF No Mandatory Mandatory
WAXING . . .
POLISHING STEP Mandatory and laborious Minimal Mandatory and oversimplified
REPAIR Easy Easy Easy
CLINICAL TIME Upon the skill of the professional Fast Fast
HYGIENE Easy Easy Using special toothbrushes and floss
. . . with specific orientations
COLOR STABILITY Excellent Excellent Needs care
REMOVAL TECHNIQUE Hard Hard Moderate
TRADEMARKS Beautifil® II, Shofu / Empress Direct®, Transil®, Ivoclar Vivadent / Elite Systemp C&B®, Ivoclar Vivadent /
Ivoclar Vivadent / Z350 XT®, 3M ESPE Transparent®, Zhermack Protemp 4®, 3M ESPE
342
Figure 2. Figure 3.
Figure 4. Figure 5.
Figure 6. Figure 7.
Figure 2. Initial smile with composite veneers exhibiting deficiency of shape and color.
Figure 3. Lateral right smile demonstrating the presence of poor veneers.
Figure 4. Initial intraoral photograph showing the presence of very opaque, dull restorations and staining at the interface.
Figure 5. Smile after removal of defective composites showing the presence of generalized diastema in the anterior superior region. Note the presence of enamel on all of the teeth involved.
Figures 6 and 7. Intraoral photographs after removing the defective composite restorations.
Figure 8. In virtue of the presence of the previous composite resin restorations, the patient demanded the fabrication of temporaries and therefore it was decided to carry out composite resin temporaries
for the six anterior superior teeth by the direct hands-free technique. (a) Spatula suitable for composite resin (Spatula Sofia®, Golgran, Brazil). (b) Composite resin (Beautifil II®, Shofu, Japan). (c) Seating of
the composite on the spatula. (d-f) Insertion of a single increment on the cervical. With a brush soaked in Modeling Resin® (Bisco, USA), the resin is spreaded throughout the labial surface.
343
Figure 9. (a) Aspect after completion of the provisional on the left side. (b-d) View of the smile after temporization.
Figure 10a-b. Final smile after cementation of the full-ceramic veneers without preparation or “contact lenses”.
Upon accomplishing the provisional of tooth #11 according to the digital planning,
the adjacent teeth may then be used as a reference for the length and tooth inclination
for the manufacturing of the other temporaries. However, patient evaluation is always best
carried out while the patient is seated, face to face, for the correction of small details of
length, tilting, incisal position and the set of temporaries, using aluminum oxide impreg-
nated discs (Figure 9a-d). At this point, it is essential to analyze the function including the
anterior guidance and disocclusion guides. Since these temporaries are fabricated joined,
344
the contacts between the teeth may be separated with serrated strips, in order to maintain
space and facilitate hygiene.
Patients with diastemas (small and parallel proximal walls) and with conoid teeth
without composite restorations prior to the impression for further fabrication of the ceramic
veneers do not necessarily require temporaries. After all, in these situations it is always
possible to fabricate the mock-up, which already provides information and confirmation of
the digital planning to the ceramist, without the need for preparations with dentin exposure.
Therefore, the execution of the provisional and their removal would be a step that would
involve greater clinical time, especially at the moment of the try-in of the ceramic veneers,
which is restricted to teeth that have suffered wear from dentin exposure. In small prepara-
tions, eg evident worn edges or sharp incisal angles, the fabrication of temporaries should
be abolished to avoid compromising the substrate available for bonding, being that it is
aaesthetically unnecessary in view of the mock-up, which was previously approved by the
patient, to be installed.
Removing these provisional veneers involves reducing the labial volume with a co-
arse grained diamond point without irrigation, slowly and without pressure, generating the
least amount of heat possible and thereby protecting the dentinopulpar complex. For the
approach of the tooth structure, using #12 scalpel blades with precise movements be-
tween the tooth and the provisional veneer, promotes displacement in fragments (Figure 6,
Chapter 12). This removal technique is possible when the composite resin layer is applied
in a single increment; therefore, a large amount of resin, which will lead to a greater de-
gree of polymerization shrinkage of the the entire set and therefore the possibility of easy
removal, by the presence of a small gap formed by the shrinkage, as well as by the limited
adhesion due to the spot etching.
CLEAR MATRIX - COMPOSITE RESIN (TABLE 1)

This technique does not rely on the professional’s technical skills, because the pre-
paration of the provisional is performed with a clear matrix which copies the wax-up diag-
nostic carried out by the technician during the previous phases of treatment planning or
through the use of the copy of a natural tooth (eg darkened with adequate form) or even of
the provisional already installed prior to the execution of the preparation.
The technique involves the use of a clear low/medium viscosity addition silicone
(Transil®, Ivoclar Vivadent, Liechtenstein; or Elite Transparent®, Zhermack, Italy). This silico-
ne is dispensed on the stone model of the diagnostic wax or directly within the patient’s
mouth, on the substrate to be copied, but requiring restorative intervention or which al-
ready possesses a provisional veneer to be replaced, provided that it has an acceptable
morphological condition (Figures 11 to 13).
This clear matrix is stored for use after the preparation (Figure 14) and subsequent
intra-oral preparations of the temporaries in order to enable the use of the composites,
due to the passage of light, less internal porosity of the composite, surface smoothness,
the addition of small increments and light-curing of composites in the absence of oxygen.
345
Figure 11. (a) Initial smile prior to the removal of the orthodontic appliance. (b) Initial intraoral photograph.
Figure 12.Initial situation immediately after removal of the upper orthodontic appliance.
Figure 13. After the improvement of shape and contour of the existing restorations (without conditioning and without proximal individualization), the clear silicone was positioned (Elite Transparent®,
Zhermack, Italy) directly within the mouth given an acceptable morphological condition.
Figure 14. Appearance after removal of composites.
Figure 15. (a) First point of etching. (b) Adhesive application. (c-d) Insertion of the composite resin in the clear silicone matrix. (e) Final appearance after matrix removal.
346
There are two possibilities for use of the clear matrix: 1: Two steps - without carrying out a spot etching and prior adhesi-
ve application, so that the composite resin, after curing, will be captured by the clear matrix during its removal. In this manner,
the margins may be extra-buccally adjusted as well as polished, and then the provisional is to be cemented with a flowable
composite (Tetric Flow® T, Ivoclar Vivadent, Liechtenstein) after spot etching and the application of the adhesive on the teeth.
Each tooth is polymerized for 30 seconds with a conventional light; and 2: Single step - after the teeth are prepared, they are
spot-etched, and then an adhesive is applied and cured. To follow, the matrix is loaded with resin, of the chosen shade, and
is gently placed on the prepared teeth. After curing, coarse finishing takes place and if necessary, the interdental contacts are
separated with serrated strips. However, in most cases the contacts are maintained together, and the patient is instructed as
to hygiene (Figure 15).
Excesses should not be kept beneath the gingival tissue, and, in this case, extremely fine diamond points are indica-
ted (#1190, KG®, Brazil), without damaging the dentogingival complex.
In case of bubbles, repairs may be carried out with composite resin, and the final appearance will be extremely agre-
eable and the patient will experience temporary functional and aaesthetic comfort while waiting for the completion of the
restorative process with ceramic veneers (Figures 16 and 17).
Figure 16. Ceramic veneers positioned on the stone model.

Figure 17a-c. Final smile.
347
SILICON MATRIX - BIS-ACRYL RESIN (TABLE 1)
The introduction of bis-acryl resin greatly facilitated the provisionalization stage by the
rapid transfer of the diagnostic wax-up to the patient’s mouth, serving as a trial step as well
as for the temporaries after patient approval of the mock-up. This type of material exhibits a
suitable surface smoothness promoting patient comfort and temporary aaesthetics, as well as
a consistency that allows for easy removal of excesses.
From the diagnostic wax-up with the optimal dimensions established by the aaesthe-
tic rehabilitation planning (Chapter 4) and a maximum of morphological characteristics and
surface texture established a silicone guide is then fabricated (Figures 18 to 20).
The fabrication of the guide involves the use of silicone, preferably laboratory (Zeta-
Figure 18a. Figure 19a. Figure 19b.
Figure 18. (a) Initial aspect of the face. (b) Initial smile. (c) Intraoral photograph revealing the presence of chipped, deficient composites from 13 to 23.
Figure 19. (a) Removal of the resin composites with disks (Sof-Lex Pop-On®, 3M ESPE, USA). (b) Careful use of the scalpel with a #12 blade. (c) Removal of the resin of tooth #11 indicating the presence
of staining on the mesial of #12. (d) Lateral aspect after removal of #12 and #13 restorations. (e) Frontal view after complete removal of deficient composite restorations. (f) Phosphoric acid etching in the
middle third. (g) Adhesive application.
348
labor®, Zhermack, Italy). First, the high viscosity paste is applied firmly on the wax model,
involving all the buccal and lingual surfaces, together with thickness to facilitate its correct
positioning within the mouth.
Following polymerization, the high viscosity silicone guide is removed from the model
and relined with low viscosity silicone (Oranwash®, Zhermack, Italy), without a relief, allowing
for a superior copy of the morphological details and surface texture from the produced wax-
-up, and the installation of temporaries with less excess and a more refined anatomy.
To facilitate removal of the excess bis-acrylic resin, the guide must be trimmed with
a scalpel blade #12 approximately 2 mm from their gingival margin following the contour
of the waxed teeth, so that there is a minimum amount of resin in the region to be easily
Figure 20a.
Figure 20c. Figure 20b.
Figure 20. (a) Tooth wax-up used and approved by the mock-up. (b) Bis-acryl resin (Protemp 4®, 3M ESPE, USA). (c) Insertion of the bis-acryl resin in the silicone guide. (d) Positioning of the guide filled
with bis-acryl resin within the mouth. Observe the removal of gross excesses with a explorer. (e) Result immediately after removal of the guide.
349
dislocated. Ideally, the palate copied by the silicone also must be trimmed out to allow for
a maximum flow of resin excesses in the region, avoiding overcontours in the mock-up.18
Then, spot etching is carried out at a point central to the prepared teeth, followed by
an adhesive application, then light curing takes place. After the discarding of the small initial
portion, which normally does not polymerize, bis-acrylic resin in a self-mixing dispensing
gun must be then dispensed on the guide so that the first portions are placed with mixing
tip touching the bottom of the guide. This maneuver minimizes the formation of bubbles in
the temporaries and promotes an even distribution of resin inside the guide. Loading the
guide should be fast due to the rapid polymerization reaction of this material, which then
should be brought to the patient’s mouth and pressed firmly into place. For this, pressure
must be carried out in the occlusal-cervical direction in the guide over the teeth not invol-
ved in the rehabilitation, to allow for the full and proper seating of the assembly.18
The excesses extravasated from the buccal and palatal surfaces are light cured and
removed with the use of explorer and tweezers, to minimize the adjustments to be made
with a scalpel blade after the curing of the resin which will occur after 5 minutes with the
silicone guide in a static position within the mouth.
After 5 minutes from the polymerization of the bis-acrylic resin and removal of the ex-
travasated excesses, the guide may then be carefully removed from the patient’s mouth.
The permanence of the provisional for an extended period requires extra care such
as:
• slight opening of the cervical embrasures, to enable cleaning with specific devices
(see Chapter 13); and
• polishing without pressure using aluminum oxide impregnated discs, abrasive ru-
bbers and felt disks impregnated with polishing paste.
Small repairs may be performed if there is bubble formation or if resin portions break,
along with the excesses. However, unlike the mock-up, which will remain in the mouth for
a short period, repairs on the provisional with bis-acryl should be accomplished after the
application of the bonding agent (Figure 21).
The removal of the fabricated provisional with bis-acryl resin is easy and without risks
of contacting the diamond point with the dental substrate.In this manner, the try-in session
and cementation with this temporization technique is faster (Figure 22).
In conclusion, it is essential that all restorative, biological and functional principles are
respected in the installed temporaries, for the rehabilitation process with ceramic veneers
is to be easily implemented. Definitively, the installation of the temporaries should be res-
tricted to the prepared teeth, since, no matter how precise they are, the provisional stage
is always difficult to control by the professional and the patient.
350
Figure 21c. Figure 22a.
Figure 21. (a) Zero pressure polishing with abrasive rubber for composite resin (Composite Technique Kit®, Shofu, Japan). (b-c) Final aspect of the provisional.
Figure 22. (a) Cemented ceramic veneers - frontal view. (b) Final intraoral lateral view. (c) Final smile. (d) Final aspect of the face.
351
Figure 22d.
352
1. Altintas SH, Yondem I, Tak O, Usumez A. Temperature rise during polymerization of three different provisional materials. Clin Oral
REFERENCES
Investig. 2008 Sep;12(3):283-6. Epub 2007 Dec 15.
2. Bagis B, Baltacioglu E, Özcan M, Ustaomer S. Evaluation of chlorhexidine gluconate mouthrinse-induced staining using a digital
colorimeter: an in vivo study. Quintessence Int. 2011;42:213-23.
3. Baratieri LN, Guimarães J. Laminados cerâmicos. In: Baratieri LN, Guimarães J, . Monteiro Jr S, Perdigão J, Bernardo JK, Zombo-
nato R, et al. Soluções clínicas: fundamentos e técnicas. Florianópolis: Ponto; 2008. p. 214-71.
4. Bennani V. Fabrication of an indirect-direct provisional fixed partial denture. J Prosthet Dent. 2000;84:364-5.
5. Burns DR, Beck DA, Nelson SK, Committee on Research in Fixed Prosthodontics of the Academy of Fixed Prosthodontics. A review
of selected dental literature on contemporary provisional fixed prosthodontic treatment: report of the Committee on Research in Fixed
Prosthodontics of the Academy of Fixed Prosthodontics. J Prosthet Dent. 2003 Nov;90(5):474-97.
6. Davidi MP, Beyth N, Sterer N, Feuerstein O, Weiss E. Effect of liquid- polish coating on in vivo biofilm accumulation on provisional
restorations: part I. Quintessence Int. 2007;38:591-6.
7. Diaz-Arnold AM, Dunne JT, Jones AH. Microhardness of provisional fixed prosthodontic materials. J Prosthet Dent. 1999;82:525-8.
8. Doray PG, Li D, Powers JM. Color stability of provisional restorative materials after accelerated aging. J Prosthodont. 2001;10:212-6.
9. Dory PG, Wang X, Powers JM, Burgess J. Accelerated aging affects color stability of provisional restorative materials. J Prosthod.
1997;6:183-8.
10. Fehling AW, Neitzke C. A direct provisional restoration for decreased occlusal wear and improved marginal integrity: a hybrid tech-
nique. J Prosthodont. 1994;3:256-60.
11. Fradeani M. Análise estética: uma abordagem sistemática para o tratamento protético. São Paulo: Quintessence; 2006.
12. Gordon JC. Provisional restorations for fixed prosthodontics. J Am Dent Assoc. 1996;127(2):249-52.
13. Hernandez EP, Oshida Y, Platt JA, et al. Mechanical properties of four methylmethacrylate-based resins for provisional fixed restora-
tions. Biomed Mater Eng. 2004;14:107-22.
14. Higashi C, Gomes JC, Kina S, Andrade OS, Hirata R. Planejamento estético em dentes anteriores. Odontologia Estética. 2006;
7:139-54.
15. Ireland MF, Dixon DL, Breeding LC, et al. In vitro mechanical property comparison of four resins used for fabrication of provisional
fixed restorations. J Prosthet Dent. 1998;80:158-62.
16. Kaiser DA. Accurate acrylic resin temporary restorations. J Prosthet Dent. 1978;39:158-61.
17. Magne P, Belser U. Bonded porcelain restorations in the anterior dentition: a biomimetic approach. Carol Stream: Quintessence;
2002.
18. Magne P, Belser UC. Novel porcelain laminate preparation approach driven by a diagnostic mock-up. J Esthet Restor Dent.
2004;16(1):7-16.
19. Nixon RL. Provisionalization for ceramic laminate veneer restorations: a clinical update. Pract Periodontics Aesthet Dent. 1997
Jan-Feb;9(1):17-27; quiz 28.
20. Sham AS, Chu FC, Chai J, Chow TW. Color stability of provisional prosthodontic materials. J Prosthet Dent. 2004;91:447-52.
21. Small BW. Indirect provisional restorations. Gen Dent. 1999;47:140-2.
22. Sorensen JA, Doherty FM, Newman MG, Flemmig TF. Gingival enhancement in fixed prosthodontics. Part I: Clinical findings. J
Prosthet Dent. 1991;65:100-7.
23. Strassler H, Lowe RA. Chairside resin-based provisional restorative materials for fixed prosthodontics. Compendium of Education
in Dentistry. 2011;32(9):10-9.
24. Turgut S, Bagis B, Ayaz EA, Ulusoy KU, Altintas SH, Korkmaz FM, Bagis N. Discoloration of provisional restorations after oral rinses.
Int J Med Sci. 2013 Aug 30;10(11):1503-9.
25. Wang RL, Moore BK, Goodacre CJ, Swartz ML, Andres CJ. A comparison of resins for fabricating provisional fixed restorations. Int
J Prosthodont. 1989 Mar-Apr;2(2):173-84.
26. Yannikakis SA, Zissis AJ, Polyzois GL, Caroni C. Color stability of provisional resin restorative materials. J Prosthet Dent. 1998;80:533-9.
27. Young HM, Smith CT, Morton D. Comparative in vitro evaluation of two provisional restorative materials. J Prosthet Dent.
2001;85:129-32.
353
SECTION IV. CEMENTATION
DENTAL ADHESION | RESIN CEMENTS | CEMENTATION
chapter 10
dental adhesion
Ana Paula Rodrigues de Magalhães | Paula de Carvalho Cardoso
Adhesion is the mechanism that binds two interfaces in close contact. The unders-
ADHESION
tanding of this mechanism was essential for the evolution of Dentistry as we know it today
and key to the development of ceramic veneers. 60 years ago a procedure like this, where
there is almost no preparation or macromechanical retention and which extremely thin por-
celain veneers are applied, was virtually impossible to be accomplished. Developments in
studies on adhesion process is directly responsible for the strength and longevity of this
restorative type.
The concept of adhesion is relatively novel in dentistry, have been introduced in 1955
by Michael Buonocore,1 which showed that when treated with 35% phosphoric acid, ena-
mel exhibited a porous surface which could then be infiltrated by resin, improving the du-
rability of the adhesion. From this work, numerous other studies have been developed to
enhance the enamel etching, including discussions over the etching of dentin and ceramics,
which has led to the development of adhesive systems.
The purpose of the adhesive restoration is to achieve a well-fit, sealed adaptation
between the restorative material and the tooth substrate.24 The fundamental mechanism of
adhesion for both enamel and dentin is based on an exchange process wherein minerals
are removed from the dental tissues and then are replaced by resinous monomers, which,
after polymerization, have become mechanically interlocked through the porosities created.2
This micromechanical interlocking of monomers to the dental substrate may result in minimal
postoperative sensitivity, improved marginal fit, preventing fluid infiltration inside the tubules
as well as acting as an elastic cushion which compensates for the forces generated by the
polymerization shrinkage of the resinous material.16,25
To reach this end it was necessary to understand the heterogeneity of both substra-
tes which occurs this union, enamel and dentin, in addition to knowing the physicochemi-
cal properties and the mechanisms of action of available adhesive systems. The biggest
challenge of dental adhesives is to promote an equally effective adhesion to these two
hard tissues of different nature.33
ENAMEL
Enamel is the outermost tissue of the tooth, composed of 96% hydroxyapatite, being
therefore, in its majority mineral.25
The use of acids for the treatment of tooth surfaces is primarily based on increased
contact surface area through the creation of microporosities, a purely physical phenome-
non. In addition, acids are also able to increase the wettability or the free surface energy,
allowing for a more intimate contact between resin and enamel, which also favors the
adhesion1,18 (Figure 1).
Enamel bonding remains the most well-established mechanism of dental adhesion.
during which, acid etching selectively dissolves enamel prisms and creates microporo-
sities, which are then penetrated by bonding agents, even hydrophobic agents, through
capillarity (Figure 2). After polymerization, small prolongations of resinous monomers are
358
formed between the prisms and create the best possible adhesion to the dental substrate. It does not only effectively seal
the margins of the restoration but also protects the vulnerable dentin adhesion from degradation.2,7,25
With ceramic veneers treated with hydrofluoric acid (see details in chapter 12) (Figure 3), the preparation should ideally
be restricted to enamel, owed to the foreseeable adhesion and superior bond strength found in this tissue (Figures 4 e 5).
Figure 1. Figure 2.
Figure 3.
Figure 1. 37% phosphoric acid (Power Etching®, BM4, Brazil).

Figure 2. Enamel etching with 35% phosphoric acid (Power Etching®, BM4, Brazil) for 30 seconds (x3,000).
Figure 3.Feldspar ceramic etched with 5% hydrofluoric acid for 90 secondss (x25,000).
SEM micrographs of Figures 2 and 3 undertaken and courtesy by Professor Sillas Duarte and Professor Neimar Sartori, UCLA, USA.
359
Figure 4.
Figure 5.
Figure 4. Adhesive interface of a porcelain veneer adhered to enamel (x3,000) (R: resin cement; HL: Hybrid layer of enamel; E: enamel).
Figure 5. Close-up view of the adhesive interface of a porcelain veneer adhered to enamel. Note the presence of the hybrid layer of enamel (x6,000) (A: adhesive layer; HL: hybrid
layer of enamel; E: enamel).
SEM micrographs of Figures 4 and 5 kindly provided by Professor Sillas Duarte and Professor Neimar Sartori, UCLA, USA.
360
DENTIN
While enamel adhesion is extremely effective and reliable, adhesion in dentin has
long since been considered difficult and less predictable.This is due to its composition and
morphology, which are very particular and greatly differ from those found in enamel. Dentin
consists mainly of water, organic matter and type I collagen.25 Dentin possesses dentinal
tubules, in which, due to differences in pressure from external and internal environments
the dentinal fluid circulates, leaving dentin naturally moist and therefore intrinsically hydro-
philic.2 Moreover, dentin is considered a dynamic tissue, which changes through aging, in
reaction to caries and restorations.30
In addition to being a very heterogeneous tissue when subjected to tooth prepa-
ration, dentin is covered by a layer of debris, which blocks the entrances of the dentinal
tubules, reducing their permeability. This layer is called the smear layer or dentin mud.2,25
This smear layer should be dissolved so that the adhesive monomers are able to enter into
contact with the dentin surface;25 furthermore modifications should be made on the dentin
surface for the mechanical interlocking of the adhesive to occur in its structure.30
The use of phosphoric acid etching for dentin, then, has the function of removing
the smear layer and promoting its demineralization, exposing the collagen fibrils (Figures
6 e 7). This layer composed by the organic components of dentin as well as hydroxyapa-
tite permeated by adhesive monomers and water constitutes what is called the hybrid
layer.20,25 In the case of ceramic veneers, adhesion entirely carried out in dentin is a chal-
lenge. Notice in Figure 8 the presence of an adhesive failure forming a gap at the interface
and the absence of resinous prolongations within the dentinal tubule (see Chapter 6, on
dentin preparation).
Several studies have been developed to understand its structure, formation and how
it can be improved, for without the formation of a well-established hybrid layer there is no
bonding.30
In recent years, discussions have been raised as to the degradation of the hybrid
layer over time caused by enzymes present on the very fibrils of the dentin collagen,
the matrix metalloproteinases.4,6,27,29 This process mainly occurs due to the discrepancy
between the depth of the demineralization of dentin and its infiltration by the adhesive mo-
nomers, resulting in voids within the deepest portions of the hybrid layer, which therefore
present exposed collagen.24,27 The presence of acidic agents, such as those produced by
bacteria, from the acid etching or from the acidic monomers of the very adhesive system
itself catalyze the action of these metalloproteinases, which initiate the degradation of the
exposed collagen, reducing the bond strength and durability of this interface.24 In an at-
tempt to increase the longevity of restorations, metalloproteinase inhibitors have been su-
ggested for their concurrent use with adhesives, such as chlorhexidine, which has shown
promising results by presentinf a chelating action over such enzymes.4,6,27,29 However, the
authors do not indicate this practice, because in addition to being another step open to
361
Figure 6.
Figure 7.
Figure 6. Human dentin etched with 37% phosphoric acid (Power Etching®, BM4, Brazil) for 15 seconds (x5000).
Figure 7. Longitudinal view of conditioned human dentin with 37% phosphoric acid (Power Etching®, BM4, Brazil) for 15 seconds (x6000).
SEM micrographs of Figures 6 and 7 undertaken and kindly provided by Professor Sillas Duarte and Professor Neimar Sartori, UCLA, USA.
362
Figure 8.
Figure 8. Adhesive interface of a porcelain veneer with margins in dentin. Note the presence of an adhesive failure forming a gap at the interface and the absence of resin plugs
inside the dentinal tubules (R: resin cement; G: interfacial gap; HL: hybrid layer in dentin; D: dentin).
SEM micrograph, courtesy of Professor Sillas Duarte and Professor Neimar Sartori, UCLA, USA.
error with respect to the adhesive luting, calcium ions released by the primer itself may
account for the loss of its inhibitory activity, with very high concentrations of chlorhexidine
required to achieve the expected goal.29 In addition, with the advent of self-etching and
multimode adhesives, this divergence between the depth of etching and penetration of
the adhesive becomes minimal, since these two processes occur simultaneously with the
use of the acidic primer, it is preferable to adopt another bonding system than to add more
steps to a procedure which is already complex.
The organic, hydrophilic and dynamic nature of dentin represent a major challenge
for adhesive interaction with this dental tissue, leading to a constant search for different
bonding strategies.
363
CLASSIFICATION (FIGURE 9)
ADHESIVE
SYSTEMS
The adhesive systems have experienced several classifications over the years: by
the number of steps, by the type of etching,and by the generations of adhesives. For
the authors, the most appropriate and current classification is the type of conditioning of
dental tissues, ie by the manner inwhich these adhesive systems interact with enamel and
dentin surfaces. The adhesive systems are thus divided into three groups: total etching;
self-etching; and most recently, the multimode adhesives.
• etchant, primer and adhesive in separate bottles

• total demineralization of enamel and dentin
• gold standard in adhesion
THREE-STEP
• technique-dependent post-operatory sensitivity
TOTAL-ETCH
• separate etchant, primer and adhesive in the same vial

TWO-STEP • total demineralization of enamel and dentin
• technique-dependent post-operatory sensitivity
• acidic primer and adhesive in separate steps

• chemical bonding to tooth structure
TWO-STEP • do not remove smear layer - lower hybrid layer
• minimized post-operatory sensitivity
SELF-ETCH
• aka “all-in-one”
• chemical bonding to tooth structure
ONE-STEP • hybrid layer thinner than two-step SEPs
• less post-operatory sensitivity
• adhesive eith acidic monomers

TWO-STEP • possibility of choosing between techniques accordant to
MULTIMODE
the clinical indication

• chemical bonding to the tooth structure
• decreased post-operatory sensitivity
ONE-STEP • selective etching of enamel is suggested for better
marginal sealing
Figure 9.
Figure 9. Schematic drawing of the current classification of adhesives.
364
Table 1. Commercial brands of adhesive systems according to the classification (Figure 9).
CLASSIFICATION COMMERCIAL BRANDS
Three-step total-etching systems Scothbond Multi Purpose® (3M ESPE), All Bond 3® (Bisco)
Three-step total-etching systems Exite F® (Ivoclar Vivadent), Exite F DSC® (Ivoclar Vivadent), Tetric N Bond® (Ivoclar Vivadent),
. Single Bond 2® (3M ESPE), Prime &Bond 2.1® (Dentsply), One Coat Bond SL® (Coltene), One Step® (Bisco),
. One Step Plus® (Bisco)
Two-step, self-etching systems Adper SE Plus® (3M ESPE), Clearfil SE Protect® (Kuraray), Clearfil SE Bond® (Kuraray), AdheSE DC® (Ivoclar
. Vivadent)
One-step, self-etching systems Clearfil S3 Bond® (Kuraray), Ace All Bond SE® (Bisco), All Bond SE® (Bisco), Adper Easy Bond® (3M ESPE)
Multimode Single Bond Universal® (3M ESPE), Clearfil Universal Bond® (Kuraray), Adhese Universal® (Ivoclar Vivadent), All-
Bond Universal® (Bisco), G-bond Plus® (GC)
TOTAL-ETCHING ADHESIVES
The oldest group of adhesives consists of the total-etching conditioning systems,
materials in which the component parts necessary for adhesion are separated: acid, pri-
mer and adhesive.30 They may require two or three steps, depending upon whether the
primer is combined or not with the adhesive in one bottle, respectively, and where the acid
from the etching step must always be isolated.2
In this etching strategy, dentin and enamel are treated with a phosphoric acid gel for
the removal of smear layer and superficial demineralization of hydroxyapatite crystals. After
this chemical conditioning, the resinous monomers (primer and adhesive) dissolved in an
organic solvent are applied to infiltrate the etched substrates.25
PHOSPHORIC ACID
Phosphoric acid, as previously discussed, is responsible for increasing the surface
free energy of enamel and create microporosities in this dental substrate.1,18 After applying
the acid on enamel, its surface should be completely dried and then the adhesive applied
directly without any influence on the dry substrate during adhesion.28 In contrast, in dentin
after rinsing of the acid, a layer of 1-10 μm3 of the surface mineral phase is completely
removed, leaving the collagen fibrils literally suspended in water.28 Drying of this layer pro-
motes collapsing of the collagen fibrils, which makes it virtually impervious to resin, as
well as the excess water which also prevents penetration, ie, it is necessary to maintain
an intermediate state of moisture to form the hybrid layer.9,28 A primer should be applied
on dentin after the acid etching to increase its surface energy, since, in contrast to what
occurs in enamel, the surface energy of dentin decreases after etching. Due to these
characteristics, the type of solvent incorporated into the adhesive systems is an important
factor when choosing the material to be used.25,28
PRIMER
Primers are mainly formed by amphoteric monomers and solvents, and correspond
to the second step of the total-etching adhesive systems with respect to dentin. Amphote-
ric monomers are those that have affinity for hydrophobic and hydrophilic substances; hy-
drophilic monomers enhance the wettability of the dental substrate, while the hydrophobic
interact and polymerize with the adhesive, which is formed by hydrophobic monomers.27
The effectiveness of adhesives on dentin is enhanced by the addition of organic solvents
with high vapor pressure to its chemical formulations; conforming to its application to the
365
dentin surface, the function of the solvent is to connect to the water present between the
collagen fibrils and induce their increased evaporation, leaving open spaces, where the
adhesive monomers should infiltrate to interlock with the collagen fibers.3,28 Acetone and
ethanol are solvents most found in adhesive systems on the market today.3
Recent investigations have shown that high immediate dentin-composite resin bond
strength values may be obtained for ethanol/water and acetone based systems provided
that they are vigorously stirred on the surface of demineralized dentin. Contrary to what is
reported in laboratory studies it is possible to achieve high bond strengths on dry deminera-
lized dentin depending on the form of the application of the adhesive, since the mechanical
force exerted on the dentin surface during the application of an adhesive may compress the
collapsed collagen fibers like a sponge,and as pressure is relieved those fibers then expand
and the adhesive solution penetrates into these regions.28
ADHESIVE
The adhesive itself is the third part of the total-etching adhesive system and is com-
posed primarily of hydrophobic and light curing monomers, which should penetrate dentin
seeking for primer to form the hybrid layer. In enamel, since there is no moisture it should
just penetrate microporosities formed by the acid etching. In addition, the current adhe-
sives offer a complex mixture of initiators, inhibitors or stabilizers, solvents and filler parti-
cles.34
In this system, as mentioned, the adhesive may be available in a separate bottle or
a bottle jointly together with the primer, which characterize the three-step, and the two-
step systems, respectively. They are the oldest adhesive systems and the most widely
used and reliable bonding strategies.30 The bond strength achieved with three-step sys-
tems, however, is still higher than that obtained for the two-step, since there is the appli-
cation of the hydrophilic primer before the hydrophobic adhesive. Research suggests that
the last water resistant layer protects the adhesive interface from degradation processes
arising from the sorption and solubility, especially over time.7,10,16 Research also shows that
preparations with all of margins in enamel exhibit greater predictability and longevity of bon-
ding with any of the total-etching adhesives, since this outer layer is capable of protecting
bonding in dentin, which is far less predictable.7
There are a number of critical steps to be performed to achieve the desired adhe-
sion with these total-etching adhesive systems,which may lead to contamination issues
of the adhesive interface before cementation. Furthermore, the difficulty of achieving the
most appropriate degree of moisture required for dentin penetration by the adhesive also
contributes to the sensitivity of the application technique by the operator.18,30 Given these
characteristics, studies have been made to seek simpler adhesives, easier to apply, prac-
tical and less sensitive to the work to be carried out by the operator for obtaining excellent
results.
366
SELF-ETCHING ADHESIVES
Multi-step adhesive systems have been on the market since the early 1990s and
today are considered the gold standard of the dental adhesives. However, there was an
increasing demand in the market for adhesive procedures for faster application and a
more simplified technique, which led to the implementation of the self-etching strategy.33
The self-etching adhesive systems do not require the initial application of an acidic
product, since they etch and penetrate simultaneously both enamel and dentin by means
of infiltration and partial dissolution of the hydroxyapatite and smear layer, without rinsing,
creating a hybrid layer incorporating minerals and products of the smear layer.2,9,10,25,30 The
elimination of the rinsing step and merely partial removal of smear layer results in a less
sensible, faster and less aggressive adhesive system, and even further reduces post-ope-
rative sensitivity.9,33
In the same manner, the total-etching adhesive systems, the self-etching systems are
also divided in accordance with the number of steps in one-step or two-step systems, that
is, if the adhesive agent is combined or separate from the primer, respectively. Two-step
systems are characterized by the use of a self-etching acidic primer followed by the appli-
cation of the adhesive.11 The one-step systems, in which the acid conditioner, primer and
adhesive are in a single bottle, are very popular in clinical practice and are also called “all-
-in-one” adhesives.2,12,13,25,31 The elimination of the acid etching has as its main advantage
ease of technique, due to elimination of the need for rinsing and the attempt of maintaining
the moisture of dentin in the right measure for successful application of the primer as well as
the adhesive.9,30 These adhesives are also classified according to their pH either as being
intermediary (pH close to 2) or strong (pH less than 1); the strongest of which are able to
form thick hybrid layers, some as thick as those obtained by phosphoric acid etching.11,17,31
In the context of the daily practice, intermediary adhesives are probably more sensitive to
the variations of the substrate: denser smear layers, biofilm or any other form of change or
that of surface contamination which may prevent the direct contact of the adhesive with the
tooth structure and therefore hinder the effective adhesion to enamel and dentin.17 Those f
self-etching adhesives ound to be strong are capable of forming resin “tags” in dentin while
the intermediary ones only slightly demineralize the “smear plug” and infiltrate the tubules
with resin, but in general the first feature generally presents the worst results of longevity and
durability of bonding than that produced by the intermediaries.33
For demineralization to occur, self-etching systems containing aqueous solutions of
acidic functional monomers, typically of phosphoric acid or carboxylic acid esters, with
a pH higher than that of phosphoric acid gels are utilized by the total-etching systems.21
From one perspective, this high pH is advantageous, since dentin may quickly reduce the
acidity of the applied primer which, after polymerization, is already neutralized.30 However,
this low acidity results in extremely superficial demineralization compared to that which is
obtained with phosphoric acid etching, especially in enamel.25,30,31 As a result the formation
of a hybrid layer thinner than conventional systems occurs, though studies have shown
that the most modern self-etching adhesives have bond strengths comparable to total-et-
ching systems, showing that the adhesion is not entirely dependent on the thickness of the
hybrid layer.9,30 In view of this characteristic, some self-etching adhesives have two diffe-
367
rent adhesive mechanisms: micromechanical bonding, dependent on the formation of the
hybrid layer; and chemical bonding dependent upon the 10-methacryloyl-oxidecil di-hy-
drogen phosphate monomer (10-MDP).9 The functional monomer 10-MDP has the strong
capacity of chemically interacting with the calcium of the residual hydroxyapatite located
around the exposed collagen fibrils, which improves the bond strength of these adhesives
to dentin and protects the collagen from the effects of degradation.5,9,12,17,19,24,31,34
The same acidic monomers inhibit the polymerization of dual curing or self-curing
composites due to the elimination of the tertiary amines of the redox initiator system in the
polymerization of these systems. As a result, the bond strength is dramatically reduced.
Therefore, self-etching adhesives are not suitable for use with dual-curing or self-curing
materials, only those of the non-acidic two-step adhesive systems may be used.10
These adhesives are highly hydrophilic, especially the one-step adhesives most of
which contain a monomer called HEMA (hydroxyethyl methacrylate), which makes this
bonding strategy susceptible to sorption and solubility processes when both come into
contact with water from the external environment as well as with the water from dentin itself
(nanoleakage).10,31 As a result, the swelling of the polymer facilitates the elution of mono-
meric hybrid layer, which may expose collagen fibers to be exposed to cleavage through
endogenous proteases.24 In order to avoid this it is essential that there exists adequate
penetration of the monomers of the adhesive agent within the tooth structure. In order for
this to occur, its active application in multiple layers is a clinical maneuver that promotes
deeper demineralization and penetration of the adhesive system, also resulting in higher
bond strengths, being that the very thin adhesive layers are susceptible to inhibition of
polymerization by oxygen.18,28
The literature is controversial about adhesion of self-etching systems to enamel, and
some studies also consider it much lower when compared to the bonding achieved by
the total-etching systems.8,25 To solve this problem, the authors have suggested roughe-
ning with burs prior to the application of the adhesive system12,14 or the selective etching
of enamel.8,12,31 Both techniques pressupose one more clinical step, which eliminates the
advantage offered by the self-etching system to provide a simplified technique for both
structures, enamel and dentin. Furthermore, the use of an exclusively enamel etching is
clinically very complex and must be performed with gels of a greater viscosity, to avoid
contact with dentin, since the acid which was previously applied to this substrate gene-
rates detrimental effects on dentin bonding.16,31 Other authors have reported excellent
clinical behavior of the self-etching two-step adhesives without any preliminary etching,
reporting only small enamel defects and surface discoloration.9,26,32 These defects were
defined as small, being that they were clinically irrelevant, so additional use of phosphoric
acid on enamel was not considered critical by these authors.9 Two-step self-etching adhe-
sive systems are still considered superior to the “all-in-one” systems.31
In clinical practice, therefore, the dentist needs to opt for a total-etching or a self-e-
tching system, depending upon the particular clinical situation. Then begin the search for
an adhesive that may be applied in both manners allowing for the professional to choose
the most appropriate adhesive protocol for each clinical situation with a single product.12
368
MULTIMODE ADHESIVES
Recently, a new generation of adhesives was launched in the market based on a
single vial that may be used as a total-etch, in combination with prior etching which utili-
zes phosphoric acid, such as self-etching or with the selective etching of enamel. Who
decides on the method of application is the dentist, based on the characteristics of the
substrate to be conditioned and the restoration to be performed. This new generation is
called the multimode or universal adhesives.22
Its adhesion to dentin is quite favorable, since it is not necessary to be concerned
with dentin moisture, because there is no etching of this substrate; there is merely the
formation of a small hybrid layer, characteristic of the self-etching adhesives, from which
adhesion is not entirely dependent.12,15 Bonding to this system is favorable because some
of the multimode adhesives, as well as certain examples of self-etching adhesives, have
the acidic monomer 10-MDP within their composition, providing chemical bonding to den-
tin.12,16,19,23 Bonding of 10-MDP to calcium creates a calcium-MDP salt which is one of
the most hydrolytically stable salts which protects the adhesive layer from degradation.16,18
In addition, one of the trademarks (Single Bond Universal®, 3M ESPE, USA), also con-
tains poly-alkenoic copolymers, found in the glass ionomer cement Vitrebond® (3M ESPE,
USA), which may promote chemical bonding to the calcium present in the hydroxyapatite.
However, some authors report that this copolymer may compete with the 10-MDP for hy-
droxyapatite, hampering the bond strength of these adhesives.12,16,18,22,23 In addition, these
monomers have a high molecular weight and may hinder the approach of the monomers
during polymerization, resulting in a lower degree of conversion.18 Performing phosphoric
acid etching in dentin towards the use of a universal adhesive is not indicated, since this
may impair the potential of chemical bonding potential between the phosphate and acidic
monomers, by removing most of the calcium, responsible for this process.5,15,23,31
For its use in enamel, however, etching is still recommended as a means to achieve
the best results.5,12,23 Although the 10-MDP monomer interacts with hydroxyapatite, appa-
rently the size and organization of hydroxiapatite within enamel disfavors the connection
to this substrate.5 The benefits of such selective etching may become evident only after a
few years, through observation of the marginal integrity of the restorations fabricated with
these adhesives.16 Active application of the adhesive is carried out with movements of a
disposable brush for 15 seconds may also increase the bond strength by the improved
penetration of the adhesive and deeper etching of the substrate.5,12,23
Its use, just like the self-etching adhesives is only indicated for restorations with a mi-
nimal amount of enamel, for those restorations where the aaesthetic demand is less critical
and in sites where there exist a high risk of application error (poor access, inadequate iso-
lation of the operative field, minimal time and poor patient cooperation, as is often the case
with children, the elderly and patients with special needs). Therefore, for those restorations
requiring strong adhesion to enamel or with great aesthetic demand, prior enamel etching
should be performed, as it may be possible to increase the bond strengths by 50%.12
All of the universal or multimode adhesives are simplified adhesives: whether they are
self-etch, or one-step adhesives; or total-etch, ie, two-step adhesives. This feature, com-
bined with good mechanical retention results up until the present, is already enough for its
369
indication.22,23 However, longitudinal clinical studies with long-term follow-ups of restorations
carried out using this adhesive system are required for its consecration when faced up
against the many adhesives that we have on the market.
Ideally, in search of the perfect adhesive system, the dentist should not be directed
CONCLUSION
to trademarks, but remember that the characteristics that should always be the goal of
each and every adhesive system. When researchers are able to develop an adhesive
system of easy clinical application which promotes increased surface free energy, crea-
tes mechanical micro-retentions, adequately penetrates the substrate without biological
damage and promotes suitable bond strengths over time, it will be possible to consider
that the ideal adhesive system was reached, combining durability, biocompatibility and
longevity.
ACKNOWLEDGEMENTS
We express our sincere thanks to Professor Sillas Duarte and Professor Neimar
Sartori, for their fundamental collaboration in preparing the SEM micrographs presented in
this chapter. Impossible for the human eye, the exploration of the microscopic world made
the study and the practice of dentistry a magical, sound and an absolute concrete routine.
Therefore, our eternal gratitude to Professor Sillas and Professor Neimar, for what that they
have done, do and will do for worldwide Dentistry!
370
1. Buonocore M. A Simple method of increasing the adhesion of acrylic filling materials to enamel surfaces. J Dent Res.
REFERENCES
1955;34:849-53.
2. Cardoso MV, de Almeida Neves A, Mine A, Coutinho E, Van Landuyt K, De Munck J, et al. Current aspects on bonding
effectiveness and stability in adhesive dentistry. Aust Dent J. 2011;56(1):31-44.
3. Cardoso PC, Lopes GC, Vieira LC, Baratieri LN. Effect of solvent type on microtensile bond strength of a total-etching one-
-bottle adhesive system to moist or dry dentin. Oper Dent. 2005;30(3):376-81.
4. Carvalho RM, Manso AP, Geraldeli S, Tay FR, Pashley DH. Durability of bonds and clinical success of adhesive restorations.
Dent Mater. 2012;28(1):72-86.
5. De Goes MF, Shinohara MS, Freitas MS. Performance of a new one-step multi-mode adhesive on etched vs non-etched
enamel on bond strength and interfacial morphology. J Adhes Dent. 2014;16(3):243-50.
6. De Munck J, Mine A, Van den Steen PE, Van Landuyt KL, Poitevin A, Opdenakker G, et al. Enzymatic degradation of adhe-
sive-dentin interfaces produced by mild self-etching adhesives. Eur J Oral Sci. 2010;118(5):494-501.
7. De Munck J, Van Meerbeek B, Yoshida Y, Inoue S, Vargas M, Suzuki K, et al. Four-year water degradation of total-etching
adhesives bonded to dentin. J Dent Res. 2003;82(2):136-40.
8. Erickson RL1, Barkmeier WW, Latta MA. The role of etching in bonding to enamel: a comparison of self-etching and etch-
-and-rinse adhesive systems. Dent Mater. 2009;25(11):1459-67.
9. Ermis RB, Kam O, Celik EU, Temel UB. Clinical evaluation of a two-step etch&rinse and a two-step self-etching adhesive
system in Class II restorations: two-year results. Oper Dent. 2009;34(6):656-63.
10. Haller B. Which self-etching bonding systems are suitable for which clinical indications? Quintessence Int. 2013;44(9):645-
61.
11. Hamouda IM, Samra NR, Badawi MF. Microtensile bond strength of etch and rinse versus self-etching adhesive systems. J
Mech Behav Biomed Mater. 2014(3):461-6.
12. Hanabusa M, Mine A, Kuboki T, Momoi Y, Van Ende A, Van Meerbeek B, et al. Bonding effectiveness of a new ‘multi-mode’
adhesive to enamel and dentine. J Dent. 2012;40(6):475-84.
13. Ito S, Tay F, Hashimoto M, Yoshiyama M, Saito T, Brackett WW, Waller JL, et al. Effects of multiple coatings of two all-in-one
adhesives on dentin bonding. J Adhes Dent. 2005;7:133-41.
14. Kanemura N, Sano H, Tagami J. Tensile bond strength to and SEM evaluation of ground and intact enamel surfaces. J Dent.
1999;27:523-30.
15. Marchesi G, Frassetto A, Mazzoni A, Apolonio F, Diolosà M, Cadenaro M, et al. Adhesive performance of a multi-mode
adhesive system: 1-year in vitro study. J Dent. 2014;42(5):603-12.
16. Mena-Serrano A1, Kose C, De Paula EA, Tay LY, Reis A, Loguercio AD, et al. A new universal simplified adhesive: 6-month
clinical evaluation. J Esthet Restor Dent. 2013;25(1):55-69.
17. Mine A1, De Munck J, Cardoso MV, Van Landuyt KL, Poitevin A, Kuboki T, et al. Bonding effectiveness of two contemporary
self-etching adhesives to enamel and dentin. J Dent. 2009;37(11):872-83.
18. Muñoz MA, Luque I, Hass V, Reis A, Loguercio AD, Bombarda NH. Immediate bonding properties of universal adhesives to
dentine. J Dent. 2013;41(5):404-11.
19. Muñoz MA, Luque-Martinez I, Malaquias P, Hass V, Reis A, Campanha NH, et al. In vitro longevity of bonding properties of
universal adhesives to dentin. Oper Dent. 2015;40(1).
20. Nakabayashi N, Kojima K, Masuhara E. The promotion of adhesion by the infiltration of monomers into tooth substrates. J
Biomed Mater Res. 1982;16:265-73.
21. Pashley DH, Tay FR. Aggressiveness of contemporary self-etching adhesives. Part II: Etching effects on unground enamel.
Dent Mater. 2001;17:430-44.
22. Perdigão J, Kose C, Mena-Serrano AP, De Paula EA, Tay LY, Reis A, et al. A new universal simplified adhesive: 18-month
clinical evaluation. Oper Dent. 2014;39(2):113-27.
23. Perdigão J, Loguercio AD. Universal or multi-mode adhesives: why and how? J Adhes Dent. 2014;16(2):193-4.
24. Perdigão J, Reis A, Loguercio AD. Dentin adhesion and MMPs: a comprehensive review. J Esthet Restor Dent.
2013;25(4):219-41.
25. Perdigão J. New developments in dental adhesion. Dent Clin North Am. 2007;51(2):333-57, viii.
26. Peumans M, De Munck J, Van Landuyt K, Lambrechts P, Van Meerbeek B. Three-year clinical effectiveness of a two-step
self-etching adhesive in cervical lesions. Eur J Oral Sci. 2005;113:512-8.
27. Reis A, Carrilho M, Breschi L, Loguercio AD. Overview of clinical alternatives to minimize the degradation of the resin-dentin
bonds. Oper Dent. 2013;38(4):E1-E25.
28. Reis A, Pellizzaro A, Dal-Bianco K, Gones OM, Patzlaff R, Loguercio AD. Impact of adhesive application to wet and dry dentin
on long-term resin-dentin bond strengths. Oper Dent. 2007;32(4):380-7.
29. Tjäderhane L, Nascimento FD, Breschi L, Mazzoni A, Tersariol IL, Geraldeli S, et al. Strategies to prevent hydrolytic degrada-
tion of the hybrid layer - A review. Dent Mater. 2013;29(10):999-1011.
30. Tyas MJ, Burrow MF. Adhesive restorative materials: a review. Austr Dent Journal. 2004;49:(3):112-21.
31. Van Landuyt KL, Peumans M, De Munck J, Lambrechts P, Van Meerbeek B. Extension of a one-step self-etching adhesive
into a multi-step adhesive. Dent Mater. 2006;22(6):533-44.
32. Van Meerbeek B, Kanumilli P, De Munck J, Van Landuyt K, Lambrechts P, Peumans M. A randomized controlled study
evaluating the effectiveness of a two-step self-etching adhesive with and without selective phosphoric-acid etching of ena-
mel Dent Mater. 2005;21:375-83.
33. Van Meerbeek B, Yoshihara K, Yoshida Y, Mine A, De Munck J, Van Landuyt KL. State of the art of self-etching adhesives.
Dent Mater. 2011;27(1):17-28.
34. Yoshida Y, Inoue S. Chemical analyses in dental adhesive technology. Japan Dent Sci Rev. 2012;48:141-52.
35. Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Torii Y, Ogawa T, et al. Self-assembled Nano-layering at the adhesive
interface. J Dent Res. 2012;91(4):376-81.
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chapter 11
resin cements
Ana Paula Rodrigues de Magalhães | Paula de Carvalho Cardoso
Cement is a substance that yields a sound bond between two surfaces. Its primary
ADHESIVE LUTING
function is to fill the small spaces between the preparation and the indirect restoration
and hold the restoration chemically, mechanically or micromechanically to the tooth, pre-
venting displacement during function.13,18 In Dentistry, three basic types of luting cements
are available: conventional or non adhesive cements (e.g., zinc phosphate); chemical
bonding cements (glass ionomer cements); and micromechanical bonding cement (resin
cements).4,10
Resin cements have a very similar composition to that of restorative resins and are
formed by a resin matrix with inorganic fillers treated with silane. However, they differ from
composite resins by the lower filler loading and lower viscosity, allowing for better flow.22
Resin cements are, in most cases, the cement of choice for luting ceramic restorations for
having superior mechanical, physical and adhesive properties when compared to other
conventional cements and due to their versatility.13,14,16,20 They provide adequate stability
in the oral environment with low solubility, high bond strengths and greater resistance to
fracture than cemented ceramic restoration, in addition to producing excellent aaesthetic
results.1,13,14,16,17
The integration between ceramic and cement through adhesive processes promo-
tes retention of the restoration; reinforces both substrates, tooth and restoration, providing
them with mechanical support; seals the tooth-restoration interface, reducing microleaka-
ge; seals the dentinal tubules; and collaborates with aaesthetics.2,4,26 Adhesion of these
resin cements is so predictable that the reduction of healthy tooth structure in order to pro-
mote physical and/or mechanical retention becomes unnecessary, making preparations
minimal or nonexistent, preserving a greater amount of healthy tooth structure and pulpal
health.7 Some disadvantages of these cements include higher cost, technical sensitivity
and difficulty of removing proximal excess.4,22
Since there are no ideal luting agents, which have an outstanding performance in
the myriad of existing clinical conditions, these cements are available on the market with
the most diverse characteristics, seeking to satisfy each of these situations with different
compositions, shades, polymerization reactions, viscosities and bonding systems, which
influence their physical properties, handling and bond strengths.4,6
The different shades of resin cements exist to allow them to adapt to the various
shades of tooth substrates and ceramics, giving the dentist the option of selecting the
ideal shade to obtain the desired aaesthetics in each case.1,3 Several studies have exa-
mined the influence of the shade of the resin cement on the final shade of the ceramic
veneer, and they all have shown a strong influence, especially in thinner ceramic restora-
tions.1,3,19,20,21,27
About the adhesive properties, resin cements may be conventional, when bonding
to the dental substrate is dependent on the previous application of an adhesive system; or
self-adhesives, which dispense the application of any bonding agent to the dental subs-
trate. Cements may also be classified according to polymerization systems in self-curing
cements, ie, cements dependent upon a chemical reaction to polymerize; light cured, or
light dependent; or double polymerization or dual, using both reactions10 (Figure 1).
Since most aaesthetic restorations require adhesive cementation and therefore ne-
374
cessitate a number of steps in the process of obtaining clinically successful adhesion, the
dentist must understand the application and mode of use of each different resin cements
for their proper selection in the pursuit of producing restorations that meet aaesthetics,
predictability and longevity.
CLASSIFICATION Conventional
• Self-curing • Dual • Light-curing
Resin Cements Self-Adhesive
• Dual
Figure 1.
Figure 1. Classification of resin cements.
Conventional resin cements are those that rely on the entire process of the adhesive
CONVENTIONAL
RESIN
CEMENTS
system to adhere to the dental substrate, either by the self-etching or total-etching techni-
que. Because of the number of steps, the technique is very sensitive to the operator and
susceptible to errors throughout the process.2,10 They are the oldest cement on the market
as well as the most used due to their proven effectiveness and because of the greater
confidence of professionals in the conventional adhesive systems.
The polymerization reaction depends on free radicals to occur and may, in the case
of conventional resin cements, be initiated by a redox chemical reaction, which characte-
rizes a cement which is chemically activated; by light, in a light-curing cement; or by both
reactions, corresponding to the dual cements.
CONVENTIONAL SELF-CURING RESIN CEMENTS

The polymerization reaction of self-curing resin cements is completely chemical, ie it
is independent of light to take place (Figure 2). These cements are the oldest, their use im-
plies the mixture of two pastes, base and catalyst which, when mixed, initiate a polymeri-
zation reaction. This reaction is dependent upon an aromatic tertiary amine, which ensures
that the polymerization reaction is complete on every level of depth of the preparation and
under every thickness of the restorative material. However, amine degrades over time, it
produces discoloration of the resin cement, which when used on very thin restorations, in-
fluences its color.15,20 This implies that using such cements requires a limited working time,
since the reaction takes place independently of the will of the operator. They are indicated
375
Figure 2. Figure 3.
Figure 2. Self-curing resin cement (Multilink N®, Ivoclar Vivadent, Liechtenstein).

Figure 3. Base paste of the dual curing resin cement (Variolink II®, Ivoclar Vivadent, Liechtenstein).
in cases where it is not possible to obtain the penetration of light necessary for the highest
possible degree of polymer conversion, as, for example, in metal-ceramic crowns, very
thick ceramics, metal cores and in situations where the restoration is not influenced by the
shade of the substrate or the cement.4,10
CONVENTIONAL DUAL RESIN CEMENTS

Dual polymerization or dual resin cements combine the desirable characteristics of a
light-curing cement and a chemical cement (Figures 3 and 4). Besides the advantage of
the chemical reaction of those monomers located in the deeper areas where light intensity
is lower, dual resin cements have been shown to have superior mechanical properties due
to the higher degree of conversion achieved by such cements, exhibiting a higher flexural
strength as well as modulus of elasticity and hardness when compared to the light-curing
or self-curing cements.3,10
These cements have been shown to exhibit a broad application for luting ceramic
crowns when the amount of light required for polymerization throughout every region of
the cement may not be obtained, since chemical polymerization is able to complement
the reaction in regions where the light did not penetrate (Figures 11 to 15). Although their
superior properties are guaranteed with an efficient curing from light sources which are
able to provide large amounts of energy.12,14
These cements are also obtained from mixing base and catalyst pastes, and like
self curing cements,also contain aromatic tertiary amine in their formulation, generating
oxidation products which may compromise the color stability of the cemented restoration
over time and are therefore contraindicated for use with veneers.3,24 These cements also
do not have a wide range of shades from the majority of manufacturers, which decreases
the dentist’s ability of combining the veneer shade with the other teeth through the use of
376
Figure 4. Figure 5.
Figure 4. Catalyst paste of the dual cure resin cement (Variolink II®, Ivoclar Vivadent, Liechtenstein).
Figure 5. Dual-cure cement RelyX Ultimate® (3M ESPE, USA).
the cement. In addition, they do not offer try-in colored pastes, which also restricts their
usage when it comes to very thin veneers. In addition, their working time and degree of
flow increases the difficulty of their use and limits their indication.8
Some authors have attempted to merely utilize the base paste without the catalyst,
of some dual cements to obtain a light-curing cement to eliminate the undesirable effect of
the tertiary amine, however, despite the favorable results, this is not the primary indication
of the manufacturer, and the best aforementioned properties of the cement are obtained
by mixing both pastes.3,20 Even with satisfactory aaesthetic outcomes, the use of base
pastes is difficult due to the lower degree of flow and a lower viscosity, especially when it
comes to ceramic veneers without wear or “contact lenses”. Therefore, due to its minimal
thickness, the ceramic may fracture due to the need for greater digital pressure to be im-
posed for the proper seating on the substrate, considering that these pastes are thicker.
It is recommended that resin cements are used with adhesive systems of the same
polymerization method, for the purpose of not having to compromise with undesirable
chemical reactions between products. In addition, dual cements should not be used with
self-etching one-step systems due to adverse chemical interaction between the acidic
monomers from the most superficial layer of the adhesive, not being completely polymeri-
zed as well as the aromatic amine resin of the dual cement.10,11
A new dual cement promises to be indicated for luting ceramic veneers, RelyX Ulti-
mate® (3M ESPE, USA) (Figure 5). According to the manufacturer, this cement does not
depend on the aromatic tertiary amine for its polymerization, but contains another compo-
nent which accomplishes the same function, giving it color stability over time. Furthermore
it offers try-in pastes for shade testing before cementation, a feature previously found only
in light-curing cements. Studies need to be made to clinically observe the actual perfor-
mance of the cement prior to its safe indication for use in ceramic veneers.
377
CONVENTIONAL LIGHT-CURING RESIN CEMENTS
Light-cured resin cements are those whose polymerization reaction is initiated by
the application of visible light (Figure 6). The main advantages of these cements are the
greatest working time and color stability.3,4
They are very suitable for veneers, contact lenses and ceramic fragments because
their color influences the final shade of the restoration (Figure 16), and present a variety of
colors and different degrees of opacity, with the corresponding shaded try-in pastes, for
verifying the result before cementation3,7,13 (Figure 7). In addition, light-curing resin cements
have greater color stability when compared to dual and self-curing resin cements, due to
the absence of the aromatic tertiary amine.3 Even more, light-curing cements enable minor
thicknesses of the cementation film by its high flow and excellent degree of viscosity, which
facilitates the removal of excess and shortens the finishing time after the cementation.3,8,23
Bonding of these cements to ceramic is strongly influenced by the degree of poly-
merization, the modulus of elasticity, the shade and the thickness of the cement. Despite
its good properties, light-curing cement is not indicated for very thick or slightly translucent
veneers or crowns due to the difficulty of light passage, and therefore in these cases the
cement will not reach an optimal degree of conversion, affecting its mechanical properties
as well as its adhesion.1,22
Low-viscosity and thermoplasticized composites are widely indicated and used for
luting prostheses,9 although our ABO-GO Dentistry Team is convinced about the precise
indication of using light-cured resin cements for luting ceramic veneers. Even with a lot of
clinical experience, it is virtually impossible for the dentist to predict the final outcome, es-
pecially in the case of ceramic veneers without reduction, whenever using a resin without
carrying out a preliminary shade try-in; a condition prevented by the protocol which utilizes
low-viscosity or thermoplasticized resins.
Figure 6. Figure 7.
Figure 6. Light-curing resin cements (Variolink Veneer®, Ivoclar Vivadent, Liechtenstein).

Figure 7. Shaded try-in light-curing resin cement pastes (Variolink Veneer®, Ivoclar Vivadent, Liechtenstein).
378
The self-adhesive resin cements can adhere to any tooth substrate without the appli-
DUAL
SELF-ADHESIVE
RESIN CEMENTS
cation of an acid or adhesive. Their application is complete in just one step, making them
clinically appealing, since they eliminate the limitations and risks of a complex conventional
bonding technique while minimizing postoperative sensitivity2,10,22 (Figures 8 to 10).
Despite their low pH (pH<2), the demineralization produced in dentin and enamel
through the use of this cement is merely superficial,2 more importantly their adhesion
mechanism is based more on chemical adhesion than on micromechanical retention.
Functional acidic monomers (10-MDP) present a chelating action over the calcium ions
of hydroxyapatite, promoting chemical bonding.2,10,18 Furthermore, the carboxyl groups
of the poly-alkenoic acid (present in RelyX U200®, 3M ESPE, USA – Figure 8) form ionic
bonds with this very calcium, further increasing the chemical bonding. The acid etching
of dentin with phosphoric acid before the application of the self-adhesive cement is detri-
mental to its bonding strength and should be avoided. Enamel etching, however, is highly
recommended, since the adhesion of cement to enamel is considered inadequate or
insufficient.2,10
Figure 8.
Figure 8. Self-adhesive dual-cure resin cement (RelyX U200®, 3M ESPE, USA).

Figure 9. Self-adhesive dual-cure resin cement (MonoCem®, Shofu, Japan).
Figure 10. Self-adhesive dual-cure resin cement (MaxCem Elite®, Kerr, USA).
379
The deterioration promoted by the water arising from dentinal tubules is still a problem
for the self-adhesive cements. The penetration of fluid during early light curing deteriorates
the quality of the cement. Studies have shown that the presence of water bubbles formed
from the dentin-cement interface on very deep preparations, can “soften” the cement and
undermine the bond strength.10
Some clinical studies have shown good results on the longevity of restorations ce-
mented with self-adhesive cements,5,25 although more longitudinal studies are necessary
before safely recommending the use of these adhesives for cementing partial restorations
such as onlays, inlays and veneers.10
Today, it may not be said that Dentistry has come to develop an ideal cement, ie,
the one with all the desirable characteristics of a cement as a complete filler of the tooth-
-restoration interface, high retention, high strength, marginal sealing, insoluble to the oral
environment, with radiopacity, good optical properties and longitudinally clinically proven.
Thus, the proper selection of the luting material is a very important step for the longevity
of ceramic veneers (Table 1). When choosing the cement, some characteristics must be
considered, such as the tooth substrate inwhich the cementation will take place; the need
for try-in pastes; the thickness and color of ceramics, as well as translucency as well as
the passage of light as regards the influence of the cement shade on the substrate; the
location of the restoration; working time; and the degree of viscosity required.2,6,8,22 As
previously disclosed as well as with everything inwhich literature has given us to date, for
the cementation of thick ceramic veneers as to the influences of the cement on the final
outcome of the shade, our team suggests the use of veneer-type light-curing cements,
based on their physical and chemical properties, and especially due to the color predic-
tability of the outcome.
Table 1.
CEMENT TYPE ADVANTAGES DISADVANTAGES INDICATIONS COMMERCIAL BRANDS
SELF-CURI Complete chemical Less work time, difficulty when Less translucent or thicker Multilink® (Ivoclar Vivadent),
NG . polymerization irrespective of removing excesses, staining, restorations: crowns, inlays Panavia 21® (Kuraray),
. the thickness of the restoration technical sensibility and onlays, PFM in short C&B® (Bisco)
. . retentive preparations and
. . metallic cores .
. . .
.
DUAL POLYMERIZATION Greater degree of conversion Color change, light curing Less translucent or thicker Variolink II® (Ivoclar Vivadent),
. due to two types of needs for optimal degree of restorations: crowns, inlays RelyX ARC® (3M ESPE),
. polymerization, greater conversion, sensible technique and onlays Nexus® (Kerr),
. control over working time, . Calibra® (Dentsply),
. easy removal of excess and . . RelyX Ultimate® (3M ESPE)*
. superior mechanical properties . . .
. . . .
LIGHT- Color stability, greater control Polymerization totally Translucent or thin Variolink Veneer® (Ivoclar
CURING . of working time, easy removal dependent on light, degree of restorations: veneers Vivadent), Rely X Veneer®
. of excess and try-in pastes conversion influenced by the and fragments (3M ESPE), Nexus® (Kerr),
. thickness of the restoration, . Vitique® (DMG)
. technical sensibility . .
Simplified technique Bond strength even lower Less translucent or thicker MonoCem® (Shofu), RelyX
involving fewer clinical than that of systems using restorations: crowns, inlays U 200® (3M ESPE), Maxcem
DUAL SELF-ADHESIVE steps and good control adhesives and onlays, fiber posts and Elite® (Kerr), Clearfill SA®
over working time PFM restorations (Kuraray), BisCem® (Bisco),
SpeedCem® (Ivoclar Vivadent)
* Specifically, RelyX Ultimate® (3M ESPE) may be used for the cementation of ceramic veneers, because it does not present discoloration after polymerization as well as features try-in pastes.
380
Figure 11f. Figure 11g. Figure 11h.
Figure 12.
Figure 11. (a) Initial photography of the face. (b) Dentolabial analysis at rest. (c) Initial smile revealing gingival inflammation and graying of tooth #21. (d-e) Lateral smile demonstrating lingual inclination of
the maxillary incisors. (f-j) Initial intraoral photographs, highlighting the endodontic access.
Figure 12. After cementation of the anatomical glass fiber post, prosthetic preparationof tooth #21 finished.
381
Figure 13. Technique conceived and developed by the ceramist Wilmar Porfirio. (a) Preparation of ceramic crown by the disilicate on disilicate technique; die of tooth #21. (b-c) Wax-up for fabrication of the
coping, leaving in a convex and the most expulsive shape as possible. (d) Coping wrapping the preparation made from E-Max® HO ingot (Ivoclar Vivadent, Liechtenstein). (e-f) Wax-up of the crown on the
E-Max® HO coping (Ivoclar Vivadent, Liechtenstein). (g-h) t Cementation of the crown fabricated with an E-Max® HT ingot (Ivoclar Vivadent, Liechtenstein) over the coping.
382
Figure 14. Ceramic crown and veneers finished (a) frontal and (b) palatal.
Figure 15. (a) Preparation of tooth substrate for cementation of the ceramic crown. Isolation and protection of adjacent teeth. (b) Etching with 37% phosphoric acid. (c) Application of the adhesive system.
(d) placement of the crown with dual-cure resin cement (Variolink II®, Ivoclar Vivadent, Liechtenstein).
Figure 16. (a) Phosphoric acid etching of tooth #11. (b) Application of the adhesive system. (c) placement of the ceramic veneer with light-cured resin cement (Variolink Veneer®, Ivoclar Vivadent,
Liechtenstein), Medium shade.
383
Figure 17a.
Figure 17b.
Figure 17. (a) Intraoral photo after cementation. (b) Final smile. (c) Final face in harmony with smile, teeth and gingiva.
384
Figure 17c.
385
1. Alqahtani MQ, Aljurais RM, Alshaafi MM. The effects of different shades of resin luting cement on the color of ceramic veneers. Dent
REFERENCES
Mater J. 2012;31(3):354-61.
2. Anchieta RB, Rocha EP, de Almeida EO, Junior AC, Martini AP. Bonding all-ceramic restorations with two resins cement techniques:
a clinical report of three-year follow-up. Eur J Dent. 2011;5(4):478-85.
3. Archegas LR, Freire A, Vieira S, Caldas DB, Souza EM. Colour stability and opacity of resin cements and flowable composites for
ceramic veneer luting after accelerated ageing. J Dent. 2011;39:804-10.
5. Behr M, Rosentritt M, Wimmer J, Lang R, Kolbeck C, Bürgers R, et al. Self-adhesive resin cement versus zinc phosphate luting
material: A prospective clinical trial begun. Dent Mater. 2009;25:601-4.
6. Blatz MB, Sadan AA, Kern M. Adhesive cementation of high-strength ceramic restorations: clinical and laboratory guidelines. Quin-
tessence Dent Technol. 2003;26:47-55.
7. Cardoso PC, Decurcio RA, Lopes LG, Souza JB. Importância da pasta de prova (try-in) na cimentação de facetas cerâmicas: relato
de caso. Rev Odontol Bras Central. 2011;20(53):53-8.
8. Cardoso PC, Luz CA, Magalhães APR, Perillo MV, Monteiro LJE, Decurcio RA. Facetas cerâmicas: como remover os excessos do
cimento resinoso? Clín - Int J Braz Dent. 2014;10(2):214-25.
9. Daronch M, Rueggeberg FA, Moss L, De Goes MF. Clinically relevant issues related to preheating composites. J Esthet Restor
Dent. 2006;18(6):340-51.
10. Duarte Jr S, Sartori N, Sadan A, Phark J. Adhesive resin cements for bonding aesthetic restorations: a review. Quintessence Dent
Technol. 2011;34:40-66.
11. Finger WJ. Compatibility between self-etching adhesive and self-curing resin by addition of anion exchange resin. Dent Mater.
2005;21:1044-50
12. Flury S, Lussi A, Hickel R, Ilie N. Light curing through glass ceramics: effect of curing mode on micromechanical properties of dual-
-curing resin cements. Clin Oral Invest. 2014;18:809-18.
13. Hill EE, Lott J. A clinically focused discussion of luting materials. Aust Dent J. 2011;56(1):67-76.
14. Kano P, Baratieri LN, Gondo R. Ceramic restorations: updates and concepts for aesthetic rehabilitation. Quintessence Dent Technol.
2010;33:199-209.
15. Karaagaclioglu L, Yilmaz B. Influence of cement shade and water storage on the final color of leucite-reinforced ceramics. Oper
Dent. 2008;22(4): 286-91.
16. Kilinc E, Antonson SA, Hardigan PC, Kesercioglu A. Resin cement color stability and its influence on the final shade of all-ceramics.
J Dent. 2011;39(1): e30-e36.
17. Lad PP, Kamath M, Tarale K, Kusugal PB. Practical clinical considerations of luting cements: A review. J Int Oral Health.
2014;6(1):116-20.
18. Ladha K, Verma M. Conventional and contemporary luting cements: an overview. J Indian Prosthodont Soc. 2010;10(2):79-88.
19. Lopes LG, Vaz MM, Magalhães APR, Cardoso PC, Souza JB, Torres EM. Shade evaluation of ceramic laminates according to
different try-in materials. Gen Dent. 2014;62(6):32-5.
20. Magalhães AP, Cardoso Pde C, de Souza JB, Fonseca RB, Pires-de-Souza FC, Lopez LG. Influence of activation mode of resin
cement on the shade of porcelain veneers. J Prosthodont. 2014;23(4):291-5.
21. Magalhães APR, Siqueira PC, Cardoso PC, Souza JB, Fonseca RB, Souza FCPP, et al. Influence of the resin cement color on the
shade of porcelain veneers after accelerated artificial aging. Rev Odontol Bras Central. 2013;21(60):11-5.
22. Namoratto LR, Ferreira RS, Lacerda RAV, Sampaio-Filho HR, Ritto FP. Cimentação em cerâmicas: evolução dos procedimentos
convencionais e adesivos. Rev Bras Odontol. 2013;70(2):142-7.
23. Peumans M, Van Meerbeek B, Lambrechts P, Vanherle G. Porcelain veneers: a review of the literature. J Dentistry. 2000;28:163-77.
24. Tanoue N, Koishi Y, Atsuta M, Matsumura H. Properties of dual-curable luting composites polymerized with single and dual curing
modes. J Oral Rehabil. 2003;30(10):1015-21.
25. Taschner M, Frankenberger R, Garcia-Godoy F, Rosenbusch S, Petschelt A, Kramer N. IPS Empress inlays luted with a self-adhe-
sive resin cement after 1 year. Am J Dent. 2009;22:55-9.
26. Xiaoping L, Dongfeng R, Silikas N. Effect of etching time and resin bond on the flexural strength of IPS e.max Press glass ceramic.
Dent Mater. 2014;30(12):e330-6.
27. Xu B, Chen X, Li R, Wang Y, Li Q. Agreement of try-in pastes and the corresponding luting composites on the final color of ceramic
veneers. J Prosthodont. 2014;23:308-12.
Figure 22d.
386
387
chapter 12
cementation
Paula de Carvalho Cardoso | Ana Paula Rodrigues de Magalhães | Rafael de Almeida Decurcio
Lúcio Monteiro | Marcus Vinícius Perillo | Terence Romano
Adhesive cementation, as discussed in the previous chapter, is considered the most
critical and meticulous step in the clinical routine, as a result of its many variables and working
time which it demands. All previous work, careful planning, accurate preparation, impres-
sions with enriching details and the suitable choice of the resin cement may be lost if the
cementation is not carried out with the utmost care. Several steps are involved in luting cera-
mic veneers, and its meticulous and careful execution is essential to the long-term success
of the rehabilitation treatment. Scientific evidence guides the strict execution of this process
towards achieving predictable results.5,19
In this chapter the cementation technique is explained in minute details: from the
preparation of the restoration to the preparation of the tooth, linking these two substrates
into one through adhesive technology.
In view of the irreversible nature of the adhesive cementation technique, the try-in stage
TRY-IN
is imperative for a successful cementation procedure which should be carried out principally
to evaluate two main factors: adaptation and shade. Before the try-in of the ceramic veneer
within the patient’s mouth, it should be ideally performed on the stone working model with
the dies sent from the ceramist, first verifying the adaptation and possible difficulties with
the insertion axis to decrease the risk of fractures during the try-in within the patient’s mouth
(Figure 5). It is always recommended that the veneers and stone models be handled at every
moment within a plastic container of medium or large size, with reasonable depth, in order to
avoid an irreversible situation such as the dropping of a ceramic restoration and consequent
fracture during every step of the trial and cementation procedure. In the case shown (Figures
1 to 5), the veneer of the conventional feldspathic ceramic system demands even further
care with handling due to its brittleness (Figure 5d).
To proceed to the try-in in the mouth it is first necessary to prepare the dental substrate,
carefully removing the temporary restoration seeking to preserve the integrity of the substrate
as well as the marginal gingival tissue. The presence of parts of the provisional on the tooth at
the moment of the try-in may hinder correct positioning, leading to mismatches or even frac-
ture of the restoration due to the use of inadequate forces.23 Bleeding of the gingival tissue is
extremely detrimental to resin cement, being that the cementation of these restorations is not
possible under absolute isolation and therefore the control of moisture and bleeding is quite
critical and complex. The penetration of blood or saliva under the cemented veneer may lead
to a brownish staining or its debonding in a short period.
For temporaries of composite or bis-acrylic resin with spot-etching and bonding, dia-
mond points are recommended for the initial volume reduction, following the utilization of
scalpel blades are utilized for the complete removal of the resin (Figure 6). In this manner,
the substrate will be fully preserved. After removal of the temporary, a delicate prophylaxis
of the substrate should be performed with the use of brushes (Hot Spot Design®, Brazil),
where the softness of the bristles are selected according to the periodontal biotype, utili-
zing pumice and water for the removal of residues. The restoration should then be positio-
ned without any material interposed between the ceramic and the tooth, for evaluation of
the adaptation after the cleansing and drying of the substrate.
390
Figure 1f. Figure 2a. Figure 2b.
Figure 3.
Figure 1. Initial photograph of the face (a). Initial smile reveals tooth # 21 with a deficient restoration. Note that the teeth were aligned, the anterior high smile line, arches and square teeth, presence of
healthy papillae and changed gingival contour in the centrals (b). Initial lateral smile revealing the commitment of tooth #21 in the dentolabial harmony (c). Intraoral photography of the deficient restoration
and presence of hypoplasia in tooth #21 (d). Detail of the central incisors (e). Initial intraoral photography of the right side (f).
Figure 2. Frontal view of the preparation. Note the important presence of enamel (a) and detail of the preparation for conventional full veneer (b).
Figure 3. Basic file sent to the ceramist for color and shape communication. This photographic sequence includes initial photos at rest and smile, and smile photograph with the color scale positioned.
The shade guide should be placed incisal to these teeth, on the same horizontal plane as the central incisors, or as close as possible on this plane, without inclinations, so there are no variations in the
amount of light received, leading to variations in the shade registration. It is also suggested the contrast modification of the picture to intensify the shade subtleties. The initial use of intraoral photographs
with a black contrast and changes in contrast assist in the determination of important anatomical details for carrying out a unitary veneer. The last photograph is of the preparation and shade guide tab,
which coordinates the ceramist in defining the shade of the ceramic system.
391
Figure 4d. Figure 5a.
Figure 5d. Figure 6a.
Figure 4. Following the impression, a direct free-hand composite resin temporary was fabricated. Initially, the etching is performed at a central point(a). Application of the dhesive system (b). Insertion of resin
composite (Empress Direct®, Ivoclar Vivadent, Liechtenstein) in a single, large increment (c). Result after polishing of resin composite temporary completed (d).
Figure 5. Feldspathic porcelain veneer (a). Lateral view of the conventional full veneer (b). Frontal view (c). Anatomical detail of the feldspathic veneer (d).
Figure 6. Aspect of the removal of the temporary restoration. Frontal aspect after reduction of the initial volume of the temporary composite resin (a). Positioning of the medium-grit rdiamond point
reducing the buccal volume (b). Final removal with #12 scalpel blade (c).
392
Figure 7a1. Figure 7a2.
Figure 7b1. Figure 7b2.
Figure 7c1. Figure 7c2.
Figure 7. Try-in of ceramic veneer. Clear try-in paste (Medium, Variolink Veneer®, Ivoclar Vivadent, Liechtenstein) (a1). Positioning of the veneer with clear try-in paste (a2). High Value try-in paste (+3,
Variolink Veneer®, Ivoclar Vivadent, Liechtenstein) (b1).Positioning of the veneer with try-in paste +3 (b2). Low Value try-in paste (-3, Variolink Veneer®, Ivoclar Vivadent, Liechtenstein) (c1). Positioning of
the veneer with try-in paste -3 (c2). Observe the change in value of the photos 7a2, 7b2 and 7c2, demonstrating the influence of the try-in paste in the final shade of the veneer.
393
Upon noting any misadaptation of the ceramic restorations, diagnosis for the pos-
sible causes is imperative. For generalized widespread mismatches, adjustments are in-
frequently indicated, as technical errors are assumed during the clinical stages of the
impression and/or laboratory production of ceramics. At this point, ideally the impression
of the case is to be repeated according to the standards provided for in Chapter 8.
For occasional mismatches, we suggest making adjustments in the substrate, not in the
ceramic restoration, using coarse-grained aluminum oxide discs (Sof-Lex Pop-On®, 3M
ESPE, USA) or F-series diamond points (KG®, Brazil), since the presence of retentions in
the preparation or in unprepared substrate is to be assumed. For specific cases and with
extensive clinical experience, one may promote the adjustment of the ceramic restoration
itself with the same discs or diamond points, provided the adjustment are not on frag-
ments or ceramic veneers without reduction.
After checking the adaptation of the restorations, the try-in step of the ceramic ve-
neer-resin cement assembly begins by utilizing shaded try-in pastes (Figure 7). Some ma-
nufacturers provide trial or try-in pastes for their corresponding light-curing resin cements,
which enable simplified application for veneers, without any interference in its seating nor in
its adaptation by its excellent flow and its easy removal from the surface being that they are
water soluble, but none follow the same standard shade system11,20,23 (Table 1). The shade
proof may not be carried out on a dry restoration, without any material, because in this
condition it appears whiter due to the phenomena of reflection and refraction of light, and
therefore do not correspond to the final color obtained after cementation.11 These pastes
are available in different shades and values coinciding with that those of the cement, which
ultimately allows for control over shade matching that permits the best aesthetic results,
since the shade of the resin cement exerts the decisive effect on the outcome of ceramic
veneers as thin as laminates.1,2,11,23,24,43,44 Although, the shade trial should be always ideally
initiated with a clear try-in paste (Figure 7a), which represents the ideal situation being that
it is not necessary to choose the exact shade of the cement for correcting color differen-
ces between the veneers and the tooth remnant. This try-in may also be performed with
water or water soluble gel, since its color is compatible with the clear paste as well as
being materials more financially advantageous.26 Through an analysis of the color obtained
with the clear paste, the need for increasing (Figure 7b) or decreasing (Figure 7c) the value
can be seen, using the whitish or yellowish pastes available. Great caution is required at
the moment of the try-in, especially when it is necessary to make use of the more shaded
and opaque pastes because they not only influence much more in the shade of the veneer
than the others,2,27 they can cause spots as they may pool more in some regions of the
veneer than in others. The try-in with shaded pastes makes it possible to choose with pre-
cision the exact cement shade to be used for cementation, which minimizes the chances
Table 1. Trademarks and try-in pastes and cements available on the market.
NAME MANUFACTURER CEMENT SHADES
Variolink Veneer Try-In Ivoclar Vivadent Variolink Veneer High, medium and low value
RelyX Veneer Try-In 3M ESPE RelyX Venner Translucent; B 0,5; white opaque; A1
Calibra Try-In Dentsply Calibra Light, medium, dark, translucent, opaque
Nexus Try-In Kerr NX3 Nexus Clear, white, yellow
394
of making mistakes and achieving a different result than expected, that is, it is another tool
for obtaining predictability.1
Technically and specifically, for the try-in of veneers, the clear paste (Medium, Va-
riolink Veneer®, Ivoclar Vivadent, Liecheinstein) is applied to the inner surface of the ce-
ramic (Figure 8a), followed by its positioning on the substrate (Figures 8b-c), the removal
of excess paste with a brush (Figure 8d) and finally, evaluation of the color obtained
(Figure 8e). In this case, the detailed analysis revealed that the aesthetic result for the
veneer with the clear paste yielded a low value, with the opportunity for its replacement
by a shaded paste with a high value may be observed. In Figure 9a, the insertion of a
high-value paste (shade +3, Variolink Veneer®, Ivoclar Vivadent, Liecheinstein) on the
inner surface of the restoration and a subsequent confirmation of the proper selection of
the resin cement to be used for the cementation step (Figure 9).
Figure 8d. Figure 8e. Figure 9a.
Figure 8. Detailed sequence of the try-in of the ceramic veneer of tooth #21. Try-in paste (Medium, Variolink Veneer®, Ivoclar Vivadent, Liechtenstein) is applied to the internal surface of the ceramic (a),
followed by positioning on the substrate (b-c), removal of excess paste with a brush (d) and finally evaluation of the shade achieved (e).
Figure 9. Higher value paste (shade +3, Variolink Veneer®, Ivoclar Vivadent, Liechtenstein) (a). Positioning of the paste on the internal surface of the restoration (b). Further confirmation of the proper
selection of the resin cement to be used in the cementation step (c).
395
Whether for ceramic veneers with or without preparation, whether for single or multiple
veneers, the try-in step is critical and should not be neglected from the rehabilitation proto-
col. By making the proper selection of the shade of the resin cement to be used, the try-in
step makes it possible to show the result in advance to the patient as well as promoting the
harmonization of the shade to match the desired result, increasing or decreasing the value
of the restored teeth. Sometimes we meet up against substrates of different shades, to be
restored with ceramic veneers without preparation, or cases associating crowns, and ve-
neers with and without wear in which the substrates are completely different. Only with the
try-in step it is possible to predict these differences in advance and enable a harmonious
aesthetic result. As described in section 5.3, bleaching enters into the rehabilitation process
as a conservative step for the purpose of equalizing and increasing the value of the subs-
trates, eliminating or decreasing the volume of tooth preparations, as well as minimizing the
variations in the use of shades of resin cement.
After try-in, there has to be certainty that both the veneer and resin cement in the
CEMENTATION
TECHNIQUE
shade selected will reproduce the planned result, being that the shade of the try-in paste
coincides with the shade of the corresponding resin cement. The preparation of the subs-
trates to be cemented initiated then. Each phase of the preparation is essential and crucial
to the predictability of this indirect restoration, which should be carried out with the utmost
care and attention. The proper preparation of the ceramic as well as the substrate and
the use of primers, adhesives and cements establish the adhesive interface, which define
the longevity of the restoration.8 It is important, alumina- and zirconia-rich oxide ceramics,
for example, are not etchable due to a lack of silica on their surface, requiring other more
complex surface treatments for their cementation, as was detailed in Chapter 7.
PREPARATION OF THE CERAMIC RESTORATION

The preparation of the ceramic begins with the establishment and protection of the
external surface of the veneer with addition silicone, to facilitate handling and to further avoid
contact of the substances utilized with the externally glazed surface. For this, a Dappen
glass is used to manipulate a small portion of high viscosity addition silicone, which is in-
serted into the Dappen dish, and the ceramic veneer is pressed over it, carefully, until the
entire external surface is covered with silicone (Figure 10a). This veneer can now be safely
prepared for adhesive cementation. The restoration should always be handled in a deep
plastic container. In the case of multiple veneers, this fixation may be carried out by a silicone
putty arranged in thick strips over the base of the plastic container, placing the restorations
one by one, side by side, already in the order of cementation.
Hydrofluoric acid is the first surface treatment of the etchable silica-containing cerami-
cs, and should be applied to dissolve the crystalline or glassy phase and to form microporo-
sities on the ceramic surface, producing small cavities, which will result in a highly retentive
surface receptive to the application of silane and cement4,6,8,18,23 (Figure 11a). Its application
time varies from ceramic to ceramic, due to the differences in composition, structural ar-
396
rangement and silica content of these materials, which should be carefully respected. For
a 10% hydrofluoric acid (Figure 10b), the indicated times in the literature are: 120 seconds
for conventional feldspathic ceramics; 60 seconds for leucite-reinforced glass-ceramics;
and 20 seconds for lithium disilicate-reinforced glass-ceramics.6,21,39 Remaining for longer
or shorter periods of time than determined have deleterious microscopic consequences on
the etched surface, which may generate few retentions or remove an excess of silica and
be detrimental to both the bonding as well as the ceramic strength itself (Figure 11b).21,42
Figure 10b.
Figure 10f.
Figure 10d. Figure 10e. Figure 10g. Figure 10h.
Figure 10. A small portion of high viscosity addition silicone is inserted into the Dappen glass and the ceramic veneer is carefully pressed over it (a). 10% hydrofluoric acid (Power CEtching®, BM4, Brazil)
(b). 5% hydrofluoric acid (Power CEtching®, BM4, Brazil) (c). Application of 10% hydrofluoric acid on the internal surface and along the internal margins of the ceramic (d-e). Removal of the acid of the
ceramic surface by rinsing with jets of air and water(f). Silane application (g-h).
397
Figure 11a1.
Figure 11a2.
Figure 11b1.
Figure 11b2.
Figure 11a1. Feldspathic ceramic without etching (a). Surface after treatment with hydrofluoric acid (b). Note that the crystalline or glassy phase was dissolved and microporosities were created
on the surface of the ceramic.
Figure 11a2. E-Max® ceramic (Ivoclar Vivadent, Liechtenstein) without etching (a). Surface after treatment with hydrofluoric acid (b).
Figure 11b1. Etched feldspathic ceramic with hydrofluoric acid for 1 minute, demonstrating the inabiity of under-etching to promote retention and promote the micro-mechanical bonding (a); for
2 minutes, ideal condition (b); and for 4 minutes, revealing overetching, smoothing the surface instead of promoting the formation of micro-retention.
Figure 11b2. E-Max® ceramic (Ivoclar Vivadent, Liechtenstein) etched with hydrofluoric acid for 10 seconds, demonstrating a sub-etching, unable to promote retention and of favoring the micro-
mechanical bonding (a); 20 seconds, ideal condition (b); e 40 seconds, revealing over-etching, by smoothing the surface instead of promoting the formation of micro-retention.
398
Studies have shown toxicity of hydrofluoric acid to the soft tissues, as well as risks
from inhalation, which is dangerous to both the dentist and the patient.30,33,45 Therefore, the
literature has indicated a minimal use in the concentration of 5%, especially for lithium di-
silicate-reinforced ceramics, requiring a limited etching time (10%, 20 seconds), although
extrapolating this time may weaken it.9,21 The utilization of 5% acid for 20 to 120 seconds
on lithium disilicate resulted in high bond strengths to the dental substrate.33,45 Brazil-Pinto9
showed a significantly decreased bond strength under shear testing when using a 10%
hydrofluoric acid for 20 seconds on lithium disilicate ceramics (16.7 MPa) compared to the
same 5% acid over the same period of time (21 MPa) with less concentrated acid, there is
superior control over the dissolution of the glassy matrix of the ceramic, and greater safety
when carrying out this etching. Definitely, the use of the 5% hydrofluoric acid (Power C
Etching®, BM4, Brazil) to etch ceramics achieves high bond strength rates and promotes
longevity of the cases (Figure 10c).
In the case described, 10% hydrofluoric acid was applied to the inner surface and
internal margins of the ceramic (Figures 10d-e), respecting the etching time for conventio-
nal feldspathic ceramics (120 seconds).
After the etching time, the acid must be removed from the ceramic surface by rinsing
with water and air jets (Figure 10f); however, residual insoluble salts from the etching may
remain attached to the surface, resulting in a white, opaque surface impairing bonding
of the cement to the ceramic surface.6,23 Removal of these residues is indicated in the
literature and may be performed in the three following most common manners: thorough
washing with air/water jets for 30 seconds; etching with 35% phosphoric acid for 30 se-
conds, followed by thorough rinsing; or an ultrasonic bath from 4 to 10 minutes. Under
scanning electron microscopy (SEM) analysis, it was observed that the etching (smear
of 37% phosphoric acid) seems to generate new waste and overetch the ceramic, which
then creates a less retentive surface and therefore becomes less favorable to bonding6,29
(Figures 12a-b). Immersion in an ultrasonic bath has shown favorable results for the remo-
val of excesses, although on a daily basis, this procedure requires more clinical time than
could possibly be advantageous.6 An abundant and meticulous rinsing with air/water jets
appears to remove excesses to a sufficient degree comparable to an ultrasonic bath wi-
thout generating further loss of structure and generating bond strengths as high or higher
than those observed for other procedures. Furthermore, for being a very simple procedure
which does not require any special equipment, additional time or costly techniques, it is
the procedure of choice for removing excesses.6
After the rinsing of the hydrofluoric acid and drying of the surface, it is time to apply
the silane (Figures 10g-h), a chemical bonding agent composed of a bifunctional mole-
cule capable of linking organic to inorganic substances, that is, a key agent for obtaining
a durable chemical bond between the methacrylate-based organic resin monomers and
the silica network of the etchable ceramic.4,8,18,22,23,39 The silane is able to penetrate the
micro-mechanical retentions formed by the etching and further cover the entire surface
of the ceramic, by chemically binding to the silica present therein where it lies waiting for
the application of a resinous material to which it binds and promotes the bonding betwe-
en ceramics and resin cement39 (Figure 13a). It is applied in a thin layer over the surface
399
Figure 12a.
Figure 12b.
Figure 12a. Cleaning of the surface of feldspathic porcelain previously etched with hydrofluoric acid, abundant rinsing with jets of air/water for 30 seconds (a) and re-etching with phosphoric acid at 37%,
creating new residues, which creates a less retentive surface and therefore less favorable for bonding (b).
Figure 12b. Cleaning of E-Max® ceramic (Ivoclar Vivadent, Liechtenstein) etched with hydrofluoric acid with abundant rinsing with jets of air/water for 30 seconds (a) and re-etching with 37% phosphoric
acid, producing new residues, which creates a less retentive surface and therefore less favorable for bonding (b).
Figure 13. Micrograph of the silane application on the conditioned and clean ceramic. Silane is able to penetrate the micro-mechanical retentions formed by etching as well as covering the entire surface
of the ceramic, chemically binding to silica and waiting for applying a resin material to which it links and promotes adhesion between the ceramic and the resin cement.
Figure 14. Scanning electron microscopy (SEM) of the adhesive applied to the etched, rinsed and silanized ceramic. Notieably how the adhesive penetrates the micro-retentions formed through etching
and due to its viscosity, where it is pooled on the surface of the ceramic, sealing these retentions and returning a perfectly smooth surface.
400
since the thicker the layer the more chance of presenting cohesive failures (Figure 10h),
60 seconds thereafter it is dried with a mild air jet for complete and total evaporation of
the solvents. Some authors recommend applying hot air jets or silane heating, with the
justification of increasing the bond strength, But studies have shown that, for bonding,
the chemical composition of silane is more important than heat, showing no differences
between those restorations cemented with or without silane heating, as long as all of the
solvent has been evaporated.13,36,39
The authors of this book, in line with other authors,32 do not recommend applying any
adhesive on the surface of the restoration, since, as observed in SEM images, adhesives
penetrate the micro-retentions formed by the etching and, due to its viscosity, results in
accumulating over the ceramic surface, sealing off these retentions and returning it back
to a perfectly smooth surface, once again eliminating the benefit of the micro-mechanical
retention (Figure 14). Hence, the layer of cement to be subsequently applied does not mix
with this adhesive layer creating an interface which is likely to fail, since there is a lack of
any mechanical interlocking of the cement on the ceramic surface, what merely remains
responsible for the cementation process is then solely the chemical bonding. In addition,
the excess adhesive may form a layer of 60 to 350 µm, which can affect the adaptation
of the ceramic restoration to the substrate, in which the ideal range is 50 to 100 µm with
a passive fit.31 Therefore, after the silane application, the ceramic surface is ready for ce-
mentation.
401
PREPARATION OF THE TOOTH SURFACE
The treatment of the tooth substrate will depend upon the selected adhesive system
(Table 2). Due to the presence of enamel in the majority of the preparations for veneers, the
cementation of ceramic veneers is usually accomplished by the 2- or 3-step total-etching
technique, as discussed in Chapter 11, with greater predictability, higher bond strengths
and long-term marginal sealing.14 However, when there is dentin, this protocol may be
subject to changes, self-etching adhesives and multimode may also be used, taking care
with the selective etching of enamel and the thickness of the adhesive layer, especially
on veneers without reduction, or with the “contact lens” type as universal adhesives are
yellower, more viscous, and thicker, being able to influence the shade of the cemented
veneer (Figure 15).
The dental treatment also depends, in addition to the adhesive, upon the type of
cement selected. If the option is for a self-adhesive cement, preparation of the tooth subs-
trate other than a simple prophylaxis is not required; for all other materials it is necessary
to pay attention to the adhesive technique of choice. Remember that the use of dual-cure
resin cements with self-etching adhesives is not indicated.15,16
Prior to the application of any material, it is necessary to isolate the adjacent gingival
tissues as well as to protect those teeth that will not be etched (Figure 16a). Tha smallest
diameter retraction cord is packed to seal the bottom of the gingival sulcus and isolate the
preparation margins against moisture. This step should only be performed in cases with a
subgingival preparation; when the preparation margin is more superficial, the cementation
is proceeded without packing the retraction cord. The adjacent teeth must be protected
with polytetrafluoroethylene tape against acid action in order to avoid problems deriving
from the excess resin cement as well as undesireable bonding to the adjacent substra-
te.5,11,12 Since absolute isolation may often hamper the complete seating of the restoration
as well as an appropriate aesthetic analysis and proper positioning of the veneers during
the cementation step, it is ideal if the operatory field be kept dry. Under relative isolation
with lip retractors (eg, Expandex®, Indusbello, Brazil), it is possible to avoid any type of
contamination on the tooth surface or ceramic veneer from saliva or blood. Then, the 35%
phosphoric acid may be applied to the dental substrate, observing the 30 second etching
time for enamel and 15 seconds for dentin (Figure 16b).23 After this time, abundant rinsing
and adequate drying are implemented, in accordance with the appropriate characteristics
of the tooth structure, and an application of the selected adhesive system, followed by
a blast of air to remove excesses as well as for obtaining a very thin film of the adhesive
(Figure 16c). After application of the adhesive without light curing, for preventing the forma-
tion of a passive film which will impede the passive seating of the ceramic,5,12 the substrate
is then ready to receive the ceramic loaded with resin cement.
CEMENT APPLICATION AND LIGHT CURING

For the proper seating of the restoration, the protective polytetrafluoroethylene tape
should be removed from the adjacent teeth. The ceramic restoration must now be loaded
with the light-curing resin cement selected during the trial phase and finally the restoration
402
Table 2. Protocols for the preparation of teeth for cementation.
SUBSTRATE ADHESIVE SYSTEM FIRST STEP SECOND STEP THIRD STEP
ENAMEL Option 1 Total-etching (3-step) Phosphoric acid 30 s Light-curing adhesive Absent
Option 2 Total-etching (2-step) Phosphoric acid 30 s Primer + Adhesive (one bottle) Absent
ENAMEL AND Option 1 Total-etching Phosphoric acid: Primer Light-curing
DENTIN . 30 s – enamel . adhesive .
(3-step)
. 15 s - dentin . .
.
Option 2 Phosphoric acid: Self-etching adhesive Self-etching adhesive
Self-etching
. 30 s – enamel first bottle second bottle
. .
Option 3 Phosphoric acid: Multi-mode adhesive ** Absent
Multi-mode
30 s – enamel
** Active application for 20 seconds followed by drying for elimination of excesses.
Figure 16a. Figure 16b1. Figure 16b2.
Figure 15. Options of adhesives for the preparation of the tooth surface (a) and evaluation of a drop of each of the adhesives available for the tooth preparation (b). Notice that the universal adhesives
(Single Bond Universal®, 3M ESPE, USA) are yellower, more viscous, and thicker, being able to influence the shade of the cemented veneer.
Figure 16. Following relative isolation with lip retractors (eg, Expandex®, Indusbello, Brazil) and retraction cord (Ultrapack®, Ultradent, USA), PTFE strips were placed (TDV®, Brazil) for the protection of the
adjacent teeth (a); 37% phosphoric acid (b1); Application of phosphoric acid on enamel for 30 seconds and 15 seconds on dentin (b2); application of selected adhesive system, followed by a blast of
air for the removal of excesses and to obtain a very thin film of the adhesive (c) and positioning with light and continuous digital pressure on the ceramic veneer with the light-curing resin cement selected
during the trial step (d).
403
is positioned with light and continuous digital pressure (Figure 16d). In the literature, there
is controversy concerning the moment of the removal of the excess cement, immediately
after the seating of the restoration with a brush3,5,12,35,38 or after a 5-second pre-polymeri-
zation.7,20,25,37
For pre-polymerization, light curing is carried out 3 to 5 seconds immediately after
the seating of the veneer; consequently, the resin cement changes to a pre-gel state, ie
between viscous and solid, producing a partially polymerized cement. This technique fa-
cilitates removal of the excess which may be carried out with a sharp-pointed instrument,
dental floss or with a #12 scalpel blade.7,37,41 However, in SEM micrographs of the margins
of prepless veneers, where the excess cement had been removed utilizing this technique,
a small “gap” between the tooth and the restoration was found, as well as the absence of
cement along the cavo-surface margins. Under SEM magnification, this space became
increasingly more evident (Figure 17).12 The same situation was observed for veneers with
preparations (Figure 17). This small “gap” is sufficient enough for the penetration of oral
fluids as well as microorganisms and the promotion of marginal leakage, which may lead
to restoration failure. Therefore, this technique should definitely be avoided.15
The systematic removal of excess uncured resin cement immediately after the se-
ating of the restoration while in the fluid phase, preferably with a dry brush, simplifies the
post-cementation finishing3,12,28,35 (Figure 17a). From the SEM images, it is clear that the
removal of excesses with a brush promotes a better marginal fit between the tooth and the
restoration and therefore favors its longevity.12 Some authors claim that in all cavo-surface
margins a residual amount of cement should be left, aimed at limiting the inhibition of poly-
merization by oxygen along these margins, preventing cracks and for the compensation of
the polymerization shrinkage of cement.38
Following which light curing should take place for 60 seconds from the buccal as-
pect with a calibrated, high-performance curing unit (Figure 18). To light cure resin cement
through ceramics, whether thin or thick, the utilization of a high curing light irradiance and/
or a longer period of light-activation should be observed, since, in most cases, light-curing
or dual cements that require a minimal amount of light to achieve the best properties are
used.17 Considering that a prolonged polymerization time may lead to faster polymerization
shrinkage of this material, damaging the tooth-restoration bonding, the authors indicate
two curing lights having multiple LEDs able to reach light intensities of up to 3,500 mW/
cm2, allowing for an excellent conversion of the cements even under ceramics: BluePha-
se® (Ivoclar Vivadent, Liecheinstein) (Figure 19a) or Valo® (Ultradent, USA) (Figure 19b). A
high-performance curing light leaves no doubt with respect to the conversion of mono-
mers to polymers and rules out the doubt of any future failure being caused by an incom-
plete polymerization of the cementation material.
404
Figure 17a.
Figure 17b.
Figure 17c.
Figure 17. Removal of excesses with a dry brush (a). SEM micrographs of the margin of prepless veneers, where the excess cement was removed utilizing the prepolymerization technique
(a) and after removal with a dry brush (b) under different 50x (17b), 100x (17c) and 1,000x (17d) magnifications. SEM micrographs of the margin of veneers with preparations, of which
excess cement was removed through the tack-cure technique (a) and after the removal of excesses with a dry brush (b) under different magnifications 50x (17e), 100x (17f) and 1,000x
(17g). Observe the formation of the small “gap” between the tooth and the restoration in the pre-polymerization technique, and under magnification of the image, this space became
increasingly more evident.
405
Figure 17d.
Figure 17e.
Figure 17f.
Figure 17g.
406
Figure 18.
Figure 18. Result immediately after cementation, still with retraction cord.
Figure 19. High-performance curing unit (Valo®, Ultradent, USA) (a) and BluePhase® (Ivoclar Vivadent, Liechtenstein) (b).
Even with an excellent marginal fit, a portion of the resin cement at the margin of
FINISHING AND
POLISHING
the indirect restoration will be exposed to the oral environment. Eventually, the exposed
cement is subject to processes of wear which will result in the formation of a “gap”, and
the consequent marginal discrepancy and marginal discoloration.15 The finishing of these
margins is a necessary condition for the longevity of the restoration without microleakage,
maintaining gingival health.
Some authors have stated that flossing the interproximal areas where the cement is
not cured is prohibited, because the force exerted may promote cracking, displacement
or removal of the restoration from the tooth.28 For this reason, after curing, the inititation
of the finishing of the coarser excesses is carried out with a serrated strip on the proximal
surfaces (Figure 20a) and, after this procedure, dental floss is to be utilized to check for
excesses still present in the proximals. If more excesses are detected in this area, abrasive
strips of decreasing grit should be used for their removal (Figure 20b).
It is also necessary to carry out the finishing of the buccal margin of the veneer with
the aid of a #12 scalpel blade (Figure 20c). Despite the cement line often being subgingi-
val, what would be ideal in addition to tact to remove excess in this region, is to visualize it.
In doing so, one should initially promote drying with air jets from a triple syringe, for at least
407
15 seconds, within the gingival sulcus to eliminate the crevicular fluid and allow for the previewing of the margin. Then, the
scalpel blade is positioned on the tooth at an angle of approximately 45º which should slide smoothly over the ceramic,
with the active tip of the blade running along the margin of cementation. After removal of the gross excesses, the retraction
cord is to be removed, when present, with an extremely fine tipped instrument (Sofia® spatula, Golgran, Brazil), to avoid
unnecessary injuries to the the gingival tissue.12
To promote a better adjustment of the cemented veneers in a second session, the gingival margin of the interface
should be polished with ceramic polishing rubbers. In line with the current literature, the Dentistry Team of ABO-GO indicate
the use of polishing rubbers (Porcelain Veneer Polishing Kit® or Porcelain Veneer Kit®, Shofu, Japan)10,34,40 (Figure 21a). Po-
lishing removes excess cement still microscopically adhered to the ceramic and the substrate, which may promote plaque
buildup or aggression to the periodontal tissue. This should be delicately carried out, following the contour of the cervical
margin of the veneer in the correct sequence, from the most abrasive rubber to the least abrasive, when promoting the
finishing and polishing of this region (Figures 21d-f).
Finally, after cementation, minor adjustments should be made for the establishment of occlusal balance, followed by
the polishing of the abraded surface with ceramic polishing rubbers (Porcelain Veneer Polishing Kit® or Porcelain Veneer
Kit®, Shofu, Japan).12 The completion of this step is performed using felt discs associated with fine diamond particle po-
lishing pastes or extrafine pumice (Figure 22).
Figure 20. Removal of proximal excesses with serrated strip (a).Abrasive strips (Epitex®, GC, USA) (b). Use of the scalpel in the gingival region (c).
Figure 21. Abrasive rubbers for ceramics (Porcelain Polishing Kit®, Shofu, Japan) (a). Sequence of abrasive rubbers in decreasing order of abrasiveness (b-c). Application within the tooth-ceramic
interface (d-f).
408
Figure 22e.
Figure 22. Final intraoral aspect (a). Frontal detail of the final result (b). Final lateral view with detail of the established anatomy (c). Final smile (d). Face, smile, gingiva and teeth in harmony (e). Responsible
ceramist: Murilo Calgaro.
409
The cementation of multiple veneers is more complex due to the need for repeating
CEMENTATION
OF MULTIPLE
VENEERS
the same process several times as well as the the risk of displacement at the moment of
cementation.
As was firstly explained, the try-in of veneers takes place on the stone model (Figure
24b) and within the mouth, for the evaluation of the adaptation, without any interposing ma-
terial, and to evaluate the color through the utilization of shaded try-in pastes. At this point,
the optimal insertion order of the veneers and their insertion axis, should be noted as well
as the setting of the best sequence for cementing the case, to avoid any possible trouble
during cementation.
After selecting the ideal resin cement, the preparation of the restorations is carried
out, which follows the same protocol as previously explained: a silicone base is made,
the restorations are secured in order to facilitate handling and avoid errors, etched with
hydrofluoric acid and, after thorough washing with water and air jets, silane is applied.
This preparation should generally be performed one restoration at a time because of the
difficulty of controlling the etching time of multiple veneers and the risk of over etching and
weakening them at the same time.
Figure 23c.
Figures 23. Initial photograph of the face (a). Initial lateral of the face (b). Dento-labial analysis at rest with minimal tooth exposure (c). Initial smile. It is noted that the teeth had become worn, squared and
were lacking dominance of the centrals (d). Initial intraoral photography with presence of healthy papillae and changed gingival contour in the centrals (e). Detail of wear of #21 tooth and change of the
gingival zenith of tooth #21(f).
Photographs of the face taken by Dudu Medeiros.
410
Figure 25a. Figure 25b. Figure 25c. Figure 25d.
Figure 24. Injected ceramic veneers showing detail of the shaded areas highlighted with a red pencil (a). Result after completion (b-c).
Figure 25. Relative isolation (a). Phosphoric acid etching of dental enamel for 30 seconds (b). Application of adhesive (c). Positioning the ceramic veneer with resin cement (d). Light curing of the
assembly (e).Cementation of tooth #11 completed (f). Prior to dental preparation of the adjacent tooth, one should look at the positioning of the veneer (g). Finalization of the cementation process (h).
411
The preparation of the teeth must be carried out according to the same protocol, tooth by tooth, cementing the
restorations one at a time, not all at once (Figure 25). The cementation of the restorations individually prevents incorrect
positioning, accidental bonding between them, and facilitates the removal of excesses, especially within the proximal
spaces.23 It is recommended that when a veneer is positioned on the tooth before light curing, the adjacent veneers are
positioned without cement or with the try-in paste to secure the correct positioning of the veneer, without rotations or dis-
placements that might impair the seating of the remaining restorations and, above all, the planned aesthetic result (Figure
25g). After cementation of the restorations one at a time, the occlusal adjustments, finishing and polishing are cerried out,
as described above (Figure 26).
By thoroughly following the complete cementation protocol, it is possible to achieve predictable results and longevity
without long-term displacements, marginal staining or periodontal injury.
Figure 26. Incisal view of the cemented veneers (a). Frontal detail after cementation (b-c). Final smile (d-f). Facial protocol photograph (g-h). Artistic photographs (i –j).
Facial and artistic photographs performed by Dudu Medeiros.
412
Figure 26i.
413
Figure 26j.
414
1. ALGhazali N, Laukner J, Burnside G, Jarad FD, Smith PW, Preston AJ. An investigationin to the effect of try-in pastes,uncuredand cured resin cements on the overall color
REFERENCES
of ceramic veneer restorations:An in vitro study. J Dent. 2010;38(2):e78-e86.
2. Alqahtani MQ, Aljurais RM, Alshaafi MM. The effects of different shades of resin luting cement on the color of ceramic veneers. Dent Mater J. 2012;31(3):354-61.
3. Anami LC, Pereira CA, Guerra E, Assunção e Souza RO, Jorge AO, Bottino MA. Morphology and bacterial colonisation of tooth/ceramic restoration interface after different
cement excess removal techniques. J Dent. 2012;40(9):742-9.
4. Anchieta RB, Rocha EP, de Almeida EO, Junior AC, Martini AP. Bonding all-ceramic restorations with two resins cement techniques: a clinical report of three-year follow-up.
Eur J Dent. 2011;5(4):478-85.
6. Belli R, Guimarães JC, Filho AM, Vieira LC. Post-etching cleaning and resin/ceramic bonding: microtensile bond strength and EDX analysis. J Adhes Dent. 2010;12(4):295-
303.
7. Blank JT. Scientifically based rationale and protocol for use of modern indirect resin inlays and onlays. J Esthet Dent. 2000;12(4):195-208.
8. Blatz MB, Sadan AA, Kern M. Adhesive cementation of high-strength ceramic restorations: clinical and laboratory guidelines. Quintessence Dent Technol. 2003;26:47-55.
9. Brazil-Pinto GB. Avaliação de diferentes métodos de aplicação do silano na resistência de união adesiva a cerâmicas vítreas [tese]. Florianópolis (SC), Universidade Federal
de Santa Catarina; 2014.
10. Camacho GB, Vinha D, Panzeri H, Nonaka T, Gonçalves M. Surface roughness of a dental ceramic after polishing with different vehicles and diamond pastes. Braz Dent
J. 2006;17:191-4.
11. Cardoso PC, Decurcio RA, Lopes LG, Souza JB. Importância da pasta de prova (try-in) na cimentação de facetas cerâmicas: relato de caso. Rev Odontol Bras Central.
2011;20(53):53-8.
12. Cardoso PC, Luz CA, Magalhães APR, Perillo MV, Monteiro LJE, Decurcio RA. Facetas Cerâmicas: como remover os excessos do cimento resinoso? Clín - Int J Braz
Dent. 2014;10(2):214-25.
13. de Carvalho RF, Martins ME, de Queiroz JR, Leite FP, Ozcan M. Influence of silane heat treatment on bond strength of resin cement to a feldspathic ceramic. Dent Mater
J. 2011;30:392-7.
14. De Munck J, Van Meerbeek B, Yoshida Y, Inoue S, Vargas M, Suzuki K, et al. Four-year Water degradation of total-etching adhesives bonded to dentin. J Dent Res.
2003;82(2):136-40.
15. Duarte Jr S, Sartori N, Sadan A, Phark J. Adhesive resin cements for bonding aesthetic restorations: a review. Quintessence Dent Technol. 2011;34:40-66.
16. Finger WJ. Compatibility between self-etching adhesive and self-curing resin by addition of anion exchange resin. Dent Mater. 2005;21:1044-50.
17. Flury S, Lussi A, Hickel R, Ilie N. Light curing through glass ceramics: effect of curing mode on micromechanical properties of dual-curing resin cements. Clin Oral Invest.
2014;18:809-18.
18. Guarda GB, Correr AB, Gonçalves LS, Costa AR, Borges GA, Sinhoreti MAC, et al. Effects of surface treatments, thermocycling, and cyclic loading on the bond strength
of a resin cement bonded to a lithium disilicate glass ceramic. Oper Dent. 2013;38(2):208-17.
19. Hilgert LA, Monteiro Jr S, Vieira LCC, Gernet W, Wolfgang ED. A escolha do agente cimentante para restaurações cerâmicas. Clín - Int J Braz Dent. 2009;5(2):194-205.
20. Hill EE, Lott J. A clinically focused discussion of luting materials. Aust Dent J. 2011;56(1):67-76.
21. Hooshmand T, Parvizi S, Keshvad A. Effect of surface acid etching on the biaxial flexural strenght of two hot-pressed glass ceramics. J Prosthod. 2008;17:415-9.
22. Kamada K, Yoshida K, Atsuta M. Effect of ceramic surface treatments on the bond of four resin luting agents to a ceramic material. J Prosthet Dent. 1998;79(5):508-13.
23. Kano P, Baratieri LN, Gondo R. Ceramic restorations: updates and concepts for aesthetic rehabilitation. Quintessence Dent Technol. 2010;33:199-209.
24. Karaagaclioglu L, Yilmaz B. Influence of cement shade and water storage on the final color of leucite-reinforced ceramics. Oper Dent. 2008;22(4):286-91.
25. Lad PP, Kamath M, Tarale K, Kusugal PB. Practical clinical considerations of luting cements: a review. J Int Oral Health. 2014;6(1):116-20.
26. Lopes LG, Vaz MM, Magalhães APR, Cardoso PC, Souza JB, Torres EM. Shade evaluation of ceramic laminates according to different try-in materials. Gen Dent.
2014;62(6):32-5.
27. Magalhães APR, Siqueira PC, Cardoso PC, Souza JB, Fonseca RB, Souza FCPP, et al. Influence of the resin cement color on the shade of porcelain veneers after acce-
lerated artificial aging. Rev Odontol Bras Central. 2013;21(60):11-5.
28. Magne P, Belser UC. Novel porcelain laminate preparation approach driven by a diagnostic “mock-up”. J Esthet Restor Dent. 2004;16(1):7-16.
29. Magne P, Cascione D. Influence of post-etching cleaning and connecting porcelain on the microtensile bond strength of composite resin to feldspathic porcelain. J Prosthet
Dent. 2006;96:354-61.
30. Ozcan M, Allahbeickaraghi A, Dündar M. Possible hazardous effects of hydrofluoric acid and recommendations for treatment approach: a review. Clin Oral Investig.
2012;16(1):15-23.
31. Pashley DH. Dentin bonding agents. Curr Opin Dent. 1992;2:46-51.
32. Passos SP, Valandro LF, Amaral R, Ozcan M, Bottino MA, Kimpara ET. Does adhesive resin application contribute to resin bond durability on etched and silanized feldspathic
ceramic? J Adhes Dent. 2008;10(6):455-60.
33. Pattanaik S, Wadkar AP. Effect of etchant variability on shear bond strength of all ceramic restorations: an in vitro study. J Indian Prosthodont Soc. 2011;11(1):55-62.
34. Raimondo RL Jr, Richardson JT, Wiedner B. Polished versus autoglazed dental porcelain. J Prosthet Dent. 1990;64(5):553-7.
35. Rufenacht CR. Fundamentos de estética. São Paulo: Quintessence; 1998.
36. Sakai M, Taira Y, Sawase T. Silane primers rather than heattreatment contribute to adhesive bonding betweentri-n-butylborane resin and a machinableleucite-reinforced
ceramic. Dent Mater J. 2011;30:854-60.
37. Taleghani M, Leinfelder KF, Lane J. Posterior porcelain bonded inlays. Compendium. 1987;8(6):410, 412, 414-5.
38. Terry DA, Touati B. Clinical considerations for aesthetic laboratory-fabricated inlay/onlay restorations: a review. Pract Proced Aesthet Dent. 2001;13(1):51-8.
39. Tian T, Tsoi JKH, Matinlinna JP, Burrow MF. Aspects of bonding between resin luting cements and glass ceramic materials. Dent Mater. 2014;30:e147–e162.
40. Vieira AC, Oliveira MC, Lima EM, Rambob I, Leite M. Evaluation of the surface roughness in dental ceramics submitted to different finishing and polishing methods. J Indian
Prosthodont Soc. 2013;13(3):290-5.
41. White SN. Adhesive cements and cementation. J Calif Dent Assoc. 1993; 21(6):30-7.
42. Xiaoping L, Dongfeng R, Silikas N. Effect of etching time and resin bond on the flexural strength of IPS e.max Press glass ceramic. Dent Mater. 2014;30(12):e330-e336.
43. Xing W, Jiang T, Ma X, Liang S, Wang Z, Sa Y, Wang Y. Evaluation of the aesthetic effect of resin cements and try-in pastes on ceromer veneers. J Dent. 2010;38(2):e87-
94.
44. Xu B, Chen X, Li R, Wang Y, Li Q. Agreement of try-in pastes and the corresponding luting composites on the final color of ceramic veneers. Journal of Prosthodontics.
2014;23:308-12.
45. Yavuz T, Dilber E, Kara HB, Tuncdemir AR, Ozturk AN. Effects of different surface treatments on shear bond strength in two different ceramic systems. Lasers Med Sci.
2013;28(5):1233-9.
415
SECTION V. FOLLOW-UP
MAINTENANCE | FAILURES OF CERAMIC VENEERS
chapter 13
maintenance
Paula de Carvalho Cardoso | Rafael de Almeida Decurcio | Pedro Luís Alves de Lima | Guido Cirilo Ferreira
In the certainty that each and every restorative procedure undergoes degradation
MAINTENANCE
over the years which develops as a consequence of a failure resulting from the process,
indicating the need for replacement, the long-term maintenance of ceramic veneers is
the final challenge of the operator. The increased survival of these restorations is directly
related to their strict maintenance, which consists of maintaining periodic clinical and ra-
diographic monitoring of the installed work and an adequate hygiene routine.
Mid- to long-term researches have shown excellent maintenance of aesthetics, high
patient satisfaction and a lack of adverse effects on gingival health.26 As a result, the main-
tenance protocol barely differs from that applied to naturally intact teeth.
Therefore, there are no specific instructions regarding oral hygiene of ceramic vene-
ers. Considering that flossing and brushing are essential, the same care and techniques
used for natural teeth may be applied to teeth with ceramic veneers.31
ROUTINE ORAL HYGIENE THERAPY

Oral hygiene therapy is directly related to motor skills, periodontal biotype (described
in section 5.2) and the new architecture between the ceramic veneers and the periodon-
tium (Table 1).
Table 1.
PATIENT PROFILE INDICATIONS
With motor difficulty Assistance of third parties or use of electric toothbrushes,
. Waterpik® (USA) (Figures 1 and 2)
No motor difficulty and thick periodontal Soft bristle toothbrush and floss (Figures 3 and 4)
biotypes
No motor difficulty and thin periodontal Soft or extra-soft bristle toothbrush and tooth tape
biotypes .
No motor difficulty and association of cervical Soft bristle toothbrush, Superfloss® (Oral-B, P&G, USA)
interdental spaces or presence of implant- or interproximal brushes (TePe®, Sweden) (Figures 5 and
supported prostheses 6)
Despite the very precise indications mentioned above, it is understood that the finan-
cial investment and time are quite substantial for the rehabilitation installed to be maintai-
ned in a simplistic manner, through the sole application of common tools and techniques
of oral hygiene.Therefore, electric toothbrushes and Waterpik® (USA) are indicated as the
gold standard with the certainty that periodontal and tooth health outcomes are proportio-
nal to the constant stimulation of maintenance of an individual’s health through the use of
technological and high performance hygiene instruments.
In situations of a very large diastema, managing closure with ceramic veneers crea-
tes a satisfactory aesthetic rehabilitation condition; however, a large gap remains between
the teeth within the cervical region. Just as occurs with rehabilitations associated with
implant-supported prostheses and veneers which even when aesthetically satisfactory,
the result still upholds an uncommon cervical area for the natural teeth making it difficult
420
to maintain the hygiene with the resulting periodontal architecture. In these situations, utili-
zing interproximal brushes (TePe®, Sweden or Curaprox®, Switzerland) and/or Superfloss®
(Oral-B, P&G, USA) is indicated.
The condition discussed above is a clinical exception and is indicated specifically for
the aforementioned areas, because patients rehabilitated with ceramic veneers normally
do not require the routine use of interproximal brushes and/or Superfloss® (Oral-B, P&G,
USA), since this could generate mechanical trauma in the gingival papillae as well as to
promote the adaptation of the local tissue for creating access that becomes increasingly
more comfortable for toothbrushing or flossing, while clinically being flattened favoring the
formation of a black triangle.
The choice of the dentifrice will fall on products with a fluorine dosage up to 1,000
ppm and with a RDA (relative dentin abrasiveness) up to 150. These agents ensure the
presence of fluoride within the oral cavity, necessary to prevent the emergence of new
caries lesions, without causing excessive wear to the ceramic.14
Figure 1. Electric toothbrush (Oral-B®, P&G, USA) for patients with motor difficulty rehabilitated with ceramic veneers.
Figure 2. Water-cleasing device (Waterpik®, USA) for patients with motor difficulty rehabilitated with ceramic veneers.
Figure 3. Soft bristle toothbrush for patients without motor difficulty and thick periodontal biotypes.
Figure 4. Dental floss for patients without motor difficulty and thick periodontal biotypes.
Figure 5. Dental floss (Superfloss®, Oral-B, P&G, USA) for patients without motor difficulty and association of cervical interdental spaces or presence of implant-supported dentures.
Figure 6. Interproximal brushes (TePe®, Sweden)for patients without motor difficulty and associated cervical interdental spaces or presence of implant-supported prostheses.
421
PROFESSIONAL HYGIENE
Beyond promoting the longevity of the rehabilitation process with ceramic veneers (Figures 7-22), regular clinical
follow-ups allow for the formulation of an early diagnosis of the problems which may arise, thus preventing the spread of
any prosthetic rehabilitation errors.
A complete intraoral radiographic series should be periodically carried out (annually) for further evaluation of the perio-
dontal, endodontic status along with checking for misadaptations, material excess and infiltrations. Besides radiographs,
the carrying out of a clinical inspection and prophylaxis become necessary (Figure 23).
Clinical inspection should be undertaken with conventional instrumentation which is adequate for the evaluation of
the appearance of carious lesions, staining along the margins of the ceramic veneers, substrate darkening and further
evaluation of the integrity of the ceramic veneers.
The clinician should also check the health of the gingival tissues. In most cases, a good marginal adaptation and
proper crown contouring allow for an effective plaque control regimen, thereby providing long-term prevention of gingival
inflammation, either partially17,19,27, or as a whole.15,28
This statement is reinforced by the fact that dental ceramics are less susceptible to the accumulation of plaque in
relation to composite resin or even he hard tooth structure.6,16 It is therefore not surprising that significant reductions in the
plaque index and bacterial count in plaque may be observed after the installation of ceramic veneers.18
The clinician should follow some specific guidelines for professional hygiene from the information obtained in the
clinical inspection.
Figure 7. Female patient complains of the darkening of tooth #21 and flaring of #12.
Figure 8. Initial intraoral photograph.
Figure 9. Detail of the darkening of tooth #21.
Figure 10. Aspect of the completed mock-up. Notice that the darkened tooth necessarily needed to be reduced.
Figure 11. Aspect after preparation completed.
Figure 12. Working model.
422
Figure 13. Finalized veneers. Notice that tooth #21 requires a ceramic system that will allow for the opacification of the substrate.
Figure 14. Modified coping (E-Max® LT, Ivoclar Vivadent, Liechtenstein), resembling the color and shape of tooth #11 (not prepared) and ceramic veneer fabricated with the same ceramic system used
for the other veneers (E-Max® HT, Ivoclar Vivadent, Liechtenstein).
Figure 15. Cementation of the modified coping.
Figure 16. Cementation of the ceramic veneer over the coping.
Figure 17. Result immediately after cementation.
Figure 18. Final intraoral photograph.
Figure 19. Final smile.
Figure 20. Oral hygiene orientations given to the patient with the use of a soft bristle toothbrush.
Figure 21. Oral hygiene instructions being given to the patient about flossing.
Figure 22. Simulation using the Waterpik® (USA) tips.
Figure 23. Inspection with millimeter probe for evaluating periodontal condition.
423
PATIENTS WITHOUT SIGNIFICANT CHANGES
The absence of staining, gingival inflammation, cracks or ceramic fractures and the
ideal shade of the substrate implies prophylaxis with a rubber cup or Robinson brush with
prophylactic paste. According to Covey & cols.,7 prophylaxis with coarse pumice resulted
in a statistically significant reduction of brightness values of the porcelain surface. Howe-
ver, it is unlikely that the change in brightness of the treated surface would be clinically
significant.2 Nevertheless, we recommend a prophylaxis with a conventional non-abrasive
prophylactic paste and brushes (Hot Spot Design®, Brazil), selecting the softness of the
bristles in accordance to the periodontal biotype (Figure 24).
Any mechanical intervention (scaling or polishing) should be performed in the ab-
sence of gingival inflammation and plaque, and the use of the following devices should
be avoided:
• sonic or ultrasonic scalers, since they can significantly damage the ceramic (chi-
pping or cracking); and
• abrasive polishing systems with sandblasting which remove the shine as well as
damage the glaze, causing a rough and stained surface.
These instruments also create adverse effects on intact enamel and should not be
used for routine tooth cleaning. They should be reserved for stubborn, hard to remove
calculus, present on intact teeth. Direct contact between the oscillatory tip and the tooth-
-restoration surface should always be avoided.
Figure 24.
Figure 24. Robinson brushes (Hot Spot Design®, Brazil) for professional cleaning.
424
PATIENTS WITH GINGIVAL ALTERATIONS
In some situations, gingival inflammation may be associated with the presence of
excesses. The removal of excesses with #12 scalpel blade will provide the necessary
conditions for the removal of plaque and maintaining periodontal health. As mentioned in
Chapter 12, for the proper removal of excesses, it is vital to provide a combination of feel,
and visualization of the cementation margin. For this maneuver, the scalpel blade is posi-
tioned at approximately a 45° angle as the blade slides over the ceramic gently with the
active tip of the blade traveling along the cementation margin. Before this, the visualization
should be benefited through adequate drying utilizing the very air jet of the triple syringe for
at least 15 seconds into the gingival sulcus, promoting the elimination of crevicular fluid to
allow for the visualization of the cementation margin.
In situations of the accumulation of subgingival calculus, periodontal curettes should
be used in accordance with the principles of the periodontal treatment, but in an extremely
delicate manner. Carefully, the direction of movement should be carried out parallel to the
gingival contour, and the movement towards the root-crown should be performed in such
a way as to prevent any contact with the margin of cementation as well as microfractures
of the ceramic margins (Figures 25a and 25b).24
Figure 25a. Inappropriate positioning of the scalers.

Figure 25b. Proper positioning of a scaler , parallel to the gingival contour.
425
PATIENTS WITH STAINING AT THE INTERFACE
Slight staining along the cervical margin as well as within the interproximal areas must
be removed with aluminum oxide polishing strips, always from the most coarse to the
finest grit (Epitex®, GC, USA) (Figure 26).
Severe staining along the interface and within the interproximal area should be re-
moved with aluminum oxide discs (Sof-Lex Pop-On®, 3M ESPE, USA) jointly with the
finishing and polishing rubbers (Standard®, Ultra® and Ultra II®, Shofu, Japan), as well as
embrasures. One should always use medium to extra-fine grit discs, avoiding those of a
coarse grain. These discs must be used with caution to avoid the formation of defects at
the interface,24 as well as changing the established morphology.
After the use of the disks and/or abrasive erasers, rinsing and careful evaluation are
performed, checking for signs of visible spots or of any feel sensation of roughness. Then
the diamond paste is applied (Porcelize®, Cosmedent, USA) with a goat hair brush or felt
wheels over the whole tooth,5 following which the paste is spread into the interproximal
area with dental floss using a back and forth movement.
The disk sequence from a coarse to a fine grit and the subsequent application of
diamond paste has as its principal objective to maintain the ceramic and dental surfaces
smooth, since the maintenance of a rough surface is more susceptible to accumulation of
plaque, greater staining and loss of aesthetic properties.
Figure 26.
Figure 26. Maintenance for patients with slightly stained veneers includes the use of aluminum oxide polishing strips from the most coarse to the
finest (Epitex®, GC, USA) at the interproximal area.
426
PATIENTS WITH TOOTH DARKENING
After some time, six years on average, in situations of extremely thin veneers, discoloration of the veneers from natural
aging of the teeth may occur. The darkened color of the natural tooth will reflect through the veneers, with the perception
that the veneer changed its color. Taking the patient’s complaint into account, in these particular situations, tooth bleaching
is indicated on the palatal surfaces of the involved teeth. Selecting the bleaching technique should be made based on the
criteria described in section 5.3.
PATIENTS WITH NOTICEABLE PARAFUNCTION

As described in section 5.4, wear from voluntary or involuntary attrition is an important reason for seeking treatment
utilizing ceramic veneers aiming at aesthetic results, even if the primary objective is functional recovery. In the case of in-
voluntary wear, linked to bruxism or similar activities to bruxism, we must bear in mind that, since the point of beginning of
this type of parafunction is irrespective of dental anatomy or the presence of occlusal interferences,20 patients treated with
ceramic veneers will overload the treatment accomplished during such parafunctional activities.
In such cases, with the intent of keeping the treatment intact, it is recommended to use splints or occlusal appliances
while sleeping and even during daytime activities like weightlifting or extreme sports.
This hard acrylic splint should preferably be prepared through the use of models assembled in a centric relationship
and possess anatomy able to generate posterior disocclusion during the excursive movements of the mandible.
Notwithstanding the aesthetic and functional results remain excellent immediately after the cementation of the cera-
LONGEVITY
mic veneers, what is most important is that the restorations exhibit maximal longevity which is ultimately related to patient’s
life expectancy. Unfortunately, the literature is not extensive in relation to the duration of restorations in the mouth. However,
the durability of veneers appears to be 10 years on average, in accordance with important clinical studies published in
recent years (Table 2).
Table 2. Clinical studies on ceramic veneers.

AUTHORS PUBLICATION DATE PERIOD SUCCESS RATE
Calamia4 1989 10 years 100%
Fradeani9 1998 Up to 6 years 98.8%
Magne et al.23 2000 4.5 years 100%
Aristidis & Dimitri1 2002 5 years 98.4%
Peumans et al.25 2004 10 years 92% (5 years)
64% (10 years)
Wiedhahn, Kerschbaum & Fasbinder30 2005 9 years 94%
Fradeani et al.10 2005 12 years 94.4%
Layton & Walton22 2007 16 years 96.1% (5 to 6 years)
93.2% (10 to 11 years)
91.3% (12 to 13 years)
73.13% (15 to 16 years)
Granell-Ruiz et al.11 2010 11 years 94%
D’Arcangelo et al.8 2012 7 years 90%
Layton, Clarke & Walton21 2012 10 years 95%
Beier et al.3 2012 20 years 93.5%
Watt, Conway29 2013 10 years 95.6%
Guess et al.13 2014 7 years 100%
427
Cervical terminations of prepless total ceramic veneers are generally positioned su-
pragingivally or at the same level of the gingival margin, characterized as a significant
clinical benefit to postoperative longevity. However, according to studies performed, even
if the margins have been located within the intrassulcular region, if the adaptation of the
veneer along with the adhesion and cementation techniques have been properly carried
out, the results will not show changes to the health of gingival tissues of the restored tooth.
Veneers exhibit excellent results owed to the use of adhesive technology which pre-
serves the maximum amount of dental tissues and even further contribute to the complete
satisfaction of the patients.1,8,10,23 In 1998, Fradeani9 found that the only flaw was found in
teeth with excessive dentin exposure; For this reason, the author recommends limiting the
preparation within enamel areas by at least 50% of the structure, particularly at the margi-
nal level, which would result in the successful fabrication of ceramic veneers.
Until the date of publication of this edition, the ABO-GO Dentistry Team has within the
last 5 years of the service of the rehabilitation protocol utilizing full veneers, both with and
without preparation, where a total of approximately 3,600 veneers having been cemented,
such data is being plotted for the presentation of long-term results. Clinical evaluation of these
veneers show a high patient satisfaction as well as aesthetics and functional reestablishment.
However, sensitivity reports associated to preparation involving dentin have been obtained,
corroborating the study of Wiedhahn, Kerschbaum & Fasbinder,30 who reported that 4 (0.6%)
and 5 (0.8%) of the evaluated veneers had exhibited postoperative sensitivity.
In clinical practice, the dilemma is on removing or maintaining existing composite resto-
rations, as discussed in Chapter 6. Restorations in good conditions and which are of a small
and medium size should be maintained for the maximum preservation of the tooth structure
as well as for the findings of Gresnigt, Kalk e Özcan,12 wherein the survival rate of ceramic
veneers cemented to teeth without interproximal restorations did not exhibit any significant
differences (96%) when compared with the existing composite restorations (93.5%).
Our clinical experience has shown an excellent acceptance of patients to total vene-
ers without preparation prior to impression and future cementation. However, it should be
emphasized, after all, even that without preparation, ceramic veneers remain an irreversible
treatment, when it comes to failure (subject described in Chapter 15), there is a need for
replacement, and this involves removal of the affected veneer with diamond points which,
due to its high flexural strength, especially in cases of lithium disilicate-reinforced ceramics,
creates some difficulty and also insecurity with respect to reduction because of the similarity
of shade between the substrate and the ceramic. Therefore, it is important to point out the
advantages of prepless veneers to the patient, but also to emphasize the possible restora-
tive cycle being installed. It is up to the patient to define the treatment, and the good sense
regarding the indication and the precise application of ethical principles extrapolated from
unnecessary treatments to be left up to the operator.
The loss of survival of these restorations is related to failures which may be caused
by numerous factors, described in detail in the next chapter.
428
Figure 27a.
Figure 27.Final Photographs promoting proper maintenance of the veneers and their resulting longevity.
429
Figure 27b.
430
REFERENCES
1. Aristidis GA, Dimitra B. Five-year clinical performance of porcelain laminate veneers. Quintessence Int. 2002;33:185-9.
2. Barucci-Pfister N, Gohring TN. Subjective and objective perceptions of specular gloss and surface roughness of aesthetic resin
composites before and after artificial aging. Am J Dent. 2009;22(2):102-10.
3. Beier US, Kapferer I, Burtscher D, Dumfahrt H. Clinical performance of porcelain laminate veneers for up to 20 years. Int J Prostho-
dont. 2012;25(1):79-85.
4. Calamia JR. Clinical evaluation of etched porcelain veneers. Am J Dent. 1989;2(1):9-15.
5. Camacho GB, Vinha D, Panzeri H, Nonaka T, Gonçalves M. Surface roughness of a dental ceramic after polishing with different
vehicles and diamond pastes. Braz Dent J. 2006;17(3):191-4.
6. Chan C, Weber H. Plaque retention on teeth restored with full-ceramic crowns: a comparative study. J Prosthet Dent.
1986;56(6):666-71.
7. Covey DA, Barnes C, Watanabe H, Johnson WW. Effects of a paste-free prophylaxis polishing cup and various prophylaxis polishing
pastes on tooth enamel and restorative materials. Gen Dent. 2011;59(6):466-73; quiz 474-5.
8. D’Arcangelo C, De Angelis F, Vadini M, D’Amario M. Clinical evaluation on porcelain laminate veneers bonded with light-cured com-
posite: results up to 7 years. Clin Oral Investig. 2012;16(4):1071-9.
9. Fradeani M. Six-year follow-up with Empress veneers. Int J Periodontics Restorative Dent. 1998;18:216-25.
10. 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.
11. Granell-Ruiz M, Fons-Font A, Labaig-Rueda C, Martínez-González A, Román-Rodríguez JL, Solá-Ruiz MF. A clinical longitudinal
study 323 porcelain laminate veneers: period of study from 3 to 11 years. Med Oral Patol Oral Cir Bucal. 2010;15(3):e531-7.
12. Gresnigt MM, Kalk W, Özcan M. Clinical longevity of ceramic laminate veneers bonded to teeth with and without existing composite
restorations up to 40 months.Clin Oral Investig. 2013;17(3):823-32.
13. Guess PC, Selz CF, Voulgarakis A, Stampf S, Stappert CF. Prospective clinical study of press-ceramic overlap and full veneer res-
torations: 7-year results. Int J Prosthodont. 2014;27(4):355-8.
14. Heintze SD, Forjanic M, Ohmiti K, Rousson V. Surface deterioration of dental materials after simulated toothbrushing in relation to
brushing time and load. Dent Mater. 2010;26(4):306-19.
15. Karlsen K. Gingival reactions to dental restorations. Acta Odontol Scand. 1970;28(6):895-904.
16. Koidis PT, Schroeder K, Johnston W, Campagni W. Color consistency, plaque accumulation, and external marginal surface charac-
teristics of the collarless metal-ceramic restoration. J Prosthet Dent. 1991;65(3):391-400.
17. Koth DL. Full crown restorations and gingival inflammation in a controlled population. J Prosthet Dent. 1982;48(6):681-5.
18. Kourkouta S, Walsh TT, Davis LG. The effect of porcelain laminate veneers on gingival health and bacterial plaque characteristics. J
Clin Periodontol. 1994;21(9):638-40.
19. Lang NP, Kiel RA, Anderhalden K. Clinical and microbiological effects of subgingival restorations with overhanging or clinically perfect
margins. J Clin Periodontol. 1983;10(6):563-78.
20. Lavigne G, Kato T, Kolta A, Sessle B. Neurobiological mechanisms involved in sleep bruxism. Crit Rev Oral Biol Med.
2003;14(1):30-46.
21. Layton DM, Clarke M, Walton TR. A systematic review and meta-analysis of thesurvival of feldspathic porcelain veneers over 5 and
10 years. Int J Prosthodont. 2012;25(6):590-603.
22. Layton D, Walton T. An up to 16-year prospective study of 304 porcelain veneers. Int J Prosthodont. 2007;20:389-96.
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;20:440-57.
24. Miller LM. Porcelain veneer protection plan: maintenance procedures for all porcelain restorations. J Esthet Dent. 1990;2(3):63-6.
25. Peumans M, De Munck J, Fieuws S, Lambrechts P, Vanherle G, Van Meerbeek B. A prospective ten-year clinical trial of porcelain
veneers. J Adhes Dent. 2004;6,:65-76.
26. Reid JS, Kinane DF, Adonogianaki E. Gingival health associated with porcelain veneers on maxillary incisors. Int J Paediatr Dent.
1991;1(3):137-41.
27. Richter-Snapp K, Aquilino SA, Svare CW, Turner KA. Change in marginal fit asrelated to margin design, alloy type, and porcelain
proximity in porcelain-fused-to-metal restorations. J Prosthet Dent. 1988;60(4):435-9.
28. Waerhaug J. Effect of toothbrushing on subgingival plaque formation. J Periodontol. 1981;52(1):30-4.
29. Watt E, Conway DI. Review suggests high survival rates for veneers at five andten years. Evid Based Dent. 2013;14(1):15-6.
30. Wiedhah K, Kerschbaum T, Fasbinder DF. Clinical long-term results with 617 Cerec veneers: a nine-year report. Int J Comput Dent.
2005;8:233-46.
31. Yesil Duymus Z, Orbak R, Dilsiz A. Abrasion resistance of veneering materials to tooth brushing. Dent Mater J. 2003;22(4):460-6.
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chapter 14
failures of ceramic veneers
Paula de Carvalho Cardoso | Rafael de Almeida Decurcio | Lúcio Monteiro
Ana Paula Rodrigues de Magalhães | Wilmar Porfírio de Oliveira
No matter how scientifically prepared and technically competent a dentist is, failures in
INTRODUCTION
the performance of dental procedures may not rarely occur and are part of the profession in
an area where accuracy is restricted to the desire of achieving it. So if the professionals are
willing to learn from the failures found, then mistakes can be beneficially helpful towards the
improvement of techniques.
For aesthetic and functional rehabilitation with ceramic veneers, flaws are present
at every step that present technical sensitivity from the selection of the case through to
the maintenance of the restorations.12,24,38 The determining factors which compromise the
final outcome involve errors in the rehabilitation planning, flaws in the laboratorial process,
inadequate prosthetic preparations, failures in the cementation process, elimination of the
finishing/polishing stage and lack of rigorous monitoring.13,16,18,38
The previous chapter emphasizes the high rates of success of ceramic veneers.
Therefore, the low failure rate may confuse the very factors which have caused these
flaws. The findings should be interpreted with caution, to create an appropriate solution
for each case.
Longitudinal clinical studies were carried out on the performance of ceramic veneers
fabricated by specialists in restorative and prosthetic dentistry, revealing acceptable results
regardless of the type of failure and/or design of the veneer.8,16,24 However, a recent study
reveals that insufficient clinical skills have resulted in failures (especially discoloration) in one
third of the patients studied. However, 82.8% of patients presented successfully installed
restorations.4
Didactically, failures and solutions will be presented in this chapter, in accordance
with the moment in the protocol of the fabrication of the ceramic veneers inwhich it oc-
curred:
• failures in the planning;
• failures in the fabrication;
• failures in the technique; and
• failures in the maintenance.
FAILURES IN THE
PLANNING
Currently, in the routine dental practice, we receive numerous cases where it is ne-
cessary to replace ceramic veneers due to the following failures in indication:
1. lack of clinical consistency between the approved mock-up and the ceramic vene-
ers installed. This point will negatively influence the success of any treatment when
the expectations and wishes of the patient expressed during the aesthetic rehabili-
tation planning stage and mock-up were not respected during the preparation of the
veneers in relation to the dental treatment. At this stage, the professional must make
use of the wax-up, mock-ups, computerized images (Chapter 4) and temporaries of
excellent quality for the patient to observe and discuss during planning, so that the
dentist may reach the expected final result;
2. delivery of ceramic veneers on substrates suitable for full crowns. In Chapter 7, on
the topic of Decision Making, The authors discuss this misconception. In summary,
434
the three key points that need to be considered with respect to the difficult deci-
sion between the fabrication of a crown or veneer are the degree of darkening, the
presence of restorations and the remaining substrate. Figures 1 to 8 demonstrate
a condition of a discolored, endodontically treated tooth (shade C4, VitaClassical®
shade guide, VITA, Germany), presence of extensive restoration (wide endodontic
access) and significant absence of enamel. As previously disclosed, the correct in-
dication is the fabrication of a full crown, because mechanical retention is extremely
important for the longevity of the restoration;
3. the fabrication of a prepless ceramic veneer, popularly known as the “contact lens”,
in situations where it would be indicated to perform conventional ceramic veneers
with tooth preparation. As described in Chapter 6 on dental preparation, proclined,
discolored teeth, and extremely large diastemata necessarily require specific pre-
parations. Figures 9 to 13 demonstrate that the error in the indication compromises
the result, confirming that teeth stained with tetracycline require substantial tooth
reduction, otherwise it would be mandatory to utilize an extremely opaque ceramic,
resulting in an artificial appearance;
4. use of ceramic veneers in mandibular or crowded anterior maxillary teeth. The term
“instant orthodontics” has often been used as a treatment option for misalignment
of teeth. In these situations, the use of veneers may be challenging due to the pros-
thetically compromised spaces, but if properly planned and well executed, offers
predictable aesthetic and long-lasting results.54 Radz50 adds that the dentist and
the patient must be well informed about the risks and benefits involved before the
initiation of any treatment.
Figure 1b.
Figure 1. Initial photograph of the face (a-b). Initial smile with the presence of a diastema between incisors, darkened tooth #11 and gingival exposure greater than 3.0 mm, and initial intraoral vision (c).
435
Figure 5b. Figure 5c. Figure 5d.
Figure 6. Figure 7.
Figure 2. Initial photograph with shade guide tab revealing darkened tooth #11 (a) and periapical radiograph revealing wide endodontic access and excessive loss of of the palatal tooth structure.
Figure 3. Aspect after periodontal surgery.
Figure 4. After removal of the palatal restoration, note the minimal thickness of the buccal enamel (a). Measurement of the buccal enamel 1.0mm confirming the need to carry out a glass fiber post
installation and the preparation for a crown. The minimal amount of buccal enamel and the need for reduction due to darkening of the tooth structure are determining factors towards the fabrication of a
crown (b).
Figure 5. Initiation of orientation grooves with a diamond point (a). Preparation of subgingival extension (b). Refinement of the preparation (c). Completed preparation (d).
Figure 6. Photograph of the substrate shade.
Figure 7. Smile outcome after cementation of the crown, and ceramic veneers reestablishing the incisal curve as well as the dominance of the centrals.
436
Figure 8 c.
Figure 8a-c. Final photographs of the face.
437
Figure 9. Patient with tetracycline staining and proclination of the incisal third (a) and intraoral photograph showing loss of enamel in the cervical third and loss of gloss (b).
Figure 10. Result after dental bleaching associated with a 2 hour daily application regimen for 22 days (Power Bleaching®, BM4, Brazil) and five sessions of in-office bleaching (Power Bleaching Office® –
37% carbamide peroxide, BM4, Brazil).
Figure 11. Working model revealing that there was no need for a reduction (a) and opaque ceramic veneers (E.max MO®, Ivoclar Vivadent, Liechtenstein) (b).
Figure 12. Try-in of ceramic veneers showing the opacity of ceramic veneers and overwhelming artificiality of the result.
Figure 13. Artificial smile revealing discolored teeth necessarily requiring preparation and, hence, planning error led to disharmonic results.
438
Such failures occur in the steps involving the ceramist, which comprise complica-
FAILURES IN
MAKING
tions such as the improper selection of the ceramic system, technique sensitivity, fracture
during laboratory preparation of the veneers and fractures during the shipping process of
the extremely physically delicate ceramic restorations.
Poorly selected ceramic is a consequence of the great challenge which communi-
cation between the ceramist and the dentist presents (Chapter 3). Therefore, to ensure
rehabilitation success, it is essential to work with a skilled ceramist, with rigid laboratory
protocol work, and constantly even aware of the ilogical technical and material evolution
involved in the process. The ceramist must be skilled not solely with respect to handling,
but especially in the restorative possibilities that each ceramic can offer with their particular
optical and physical characteristics. Yet, it is essential that the ceramist is aware of their
indications and applications.
In situations with a high degree of complexity involving fragments, prepless veneers,
conventional veneers, full crowns and implant-supported crowns, the biomimetic cha-
racteristics of ceramic behave differently. Given this situation, the aesthetic results of the
crowns may differ from the veneers which may be presented as being grayish when using
excessively translucent ceramic systems, and/or artificial, with the use of opaque cerami-
cs (Figures 14 to 18).
Thus, the use of different degrees of translucency of ceramic systems is required.
It is suggested for conventional and implant-supported crowns utilizing E.max® copings
(Ivoclar Vivadent, Liechtenstein) MO (medium opacity) and HO (high opacity), to be cove-
red with high translucency crowns (HT E.max®, Ivoclar Vivadent, Liechtenstein) and low
translucency ingots (LT E.max® Ivoclar Vivadent, Liechtenstein). This technique, described
in Chapter 12, is defined as the “Disilicate On Disilicate” technique.
Fractures of ceramic veneers prior to cementation occur due to the meticulousness
of the laboratory technique. During the laboratory preparation of the veneers, the minimal
thickness and the obligation of reproducing the anatomical details like texture generates
fractures during the handling, the technique of finishing and polishing, and even in the
process of shipping it to the dentist.
Facture from shearing prevents any possibility of repair, necessitating the preparation
of a new ceramic restoration. On the other hand, a uniform fracture in distinct fragments
may facilitate, being repaired by the ceramist or even by the clinician. There are two situ-
ations for the resolution of failure: (1) cementation of fractured restorations as fragments,
with the understanding of the interaction between them as well as properly explaining the
occurrence to the patient; and (2) the laboratory bonding of the fractured restorations
prior to cementation (Figures 19 to 21). Both imply extreme caution when handling the
restorations until they are cemented.
Another important laboratory detail, which may also generate failure is the die spacer,
which, when incorrectly applied, may promote an inappropriate line of cementation. The-
refore, this spacer must be applied carefully, respecting the manufacturer’s instructions,
in avoidance of an undesired film thickness and subsequent failure at the restoration-ce-
ment-tooth interface.7
439
Figure 14. Patient with diastemata, absence of tooth #12 and the presence of a primary tooth (#53) (a). Try-in of ceramic veneers and implant-supported crown of #13 revealing graying of the crown
due to improper selection of the ceramic system (b). Result after replacement of the grayish crown by a crown with e.max® coping (e.max MO, Ivoclar Vivadent, Liechtenstein) and a veneering ceramic
(e.max HT®, Ivoclar Vivadent, Liechtenstein), similar to that used in the other ceramic veneers (c).
Figure 15. Initial smile with presence of defective restorations on teeth #11 and #12 (a). Initial intraoral view (b).
Figure 16. Work model after crown preparation of teeth #11 and #12 (a). Ceramic crowns and veneers on the working model (b).
Figure 17. Aspect after the try-in of crowns and ceramic veneers (a). Notice that the crowns presented an inadequate shade in relation to the veneers, grayish due to the use of an excessively
translucent ceramic system (b).
Figure 18. Smile after the use of a suitable ceramic system (E.max®, Ivoclar Vivadent, Liechtenstein) MO (medium opacity), and over them the production of crowns using E.max® ingots (Ivoclar Vivadent,
Liechtenstein) HT (high translucency) for the crowns of teeth # 11 and # 12 (a) and final intraoral photograph.
440
Figure 20e.
Figure 21.
Figure 19. Initial introral view revealing large diastemata and tooth discoloration.
Figure 20. Fractured ceramic veneer before the try-in. Observe the recovered ceramic fragment (a). Application of a proprietary bonding agent from the E.max® system (Ivoclar Vivadent, Liechtenstein)
(b). Fragment reattachment (c). Final aspect of the cementation (d). Ceramic veneers placed on the working model (e).
Figure 21. Ceramic veneers immediately after cementation, restoring the harmony.
441
Technical failures involve all of the complications occurring during impression, try-in
FAILURES IN
THE TECHNIQUE
and cementation steps including those described below.
INACCURATE IMPRESSION
In most cases, the presence of bleeding is associated with gingival inflammation. In
such cases, using a hemostatic agent is not recommended, because its presence may
negatively compromise the reproduction of the cervical margin, due to the hydrophobic na-
ture of the PVS, the indicated impression material was discussed in Chapter 8. The ceramic
veneers are the final step in the rehabilitation process, so each and every infectious or in-
flammatory order must be suppressed with specific support therapy. For this situation we su-
ggest the establishment of new plaque control sessions as well as oral hygiene counseling
for evaluation and scheduling of the impression step. Specifically, on occasions of bleeding
caused by immediate trauma and induced bleeding (eg, unintentional gingival trauma by the
cord-packing instrument or from the contact of the diamond points during the refinement of
the preparation), the recommendation is to wait a minimum of 7 minutes for remission of the
bleeding and, after rinsing, to resume the impression process, provided that the problem is
thoroughly restricted to the above.
Still on this same topic, inadequate selection of trays may generate considerable dis-
tortions in the mold, whether through their insertion into the mouth, or during their removal,
inappropriate sized trays are capable of promoting deformations. Moreover, the absence
of an adhesive for addition silicone, described in Chapter 8, may also generate distortions
in the mold obtained, by loosening the impression material from the tray which would ne-
cessarily require a new impression.
Another situation which needs much attention is the quantity of low viscosity material
dispensed over the involved teeth within the impression. The low viscosity material should
involve all of the teeth in the arch, and not be limited to merely those teeth that eventually will
receive the ceramic veneers. It is common to obtain models which are unstable and with
striations, which impliy a loss of the working model and the consequent postponement for
a new impression.
The disobeying of the obligation of performing a new impression in the aforemen-
tioned situations may produce working models with imperfections and consequently the
production of maladapted veneers. It is not always possible to make adjustments of this
nature and adapt it to the substrate or to imagine that the resin cement is able to compen-
sate for adaptation = failures, this will lead to new impression sessions, one more appoint-
ment for the laboratory preparation of the veneers as well as the patient’s disappointment.
The veneer should always exhibit a passive adaptation, even when it presents an axis
of insertion, and when this does not occur, it is necessary to make subtle adjustments.
For minimal misadaptation a protocol for determining the interference site and subsequent
adjustment is created. Interferences can be observed in the adaptation, especially in the
cases of proximal involvement (Class III and Classe IV involved in the preparation) (Figures
22 to 23). The first step is to dispense of the low viscosity vinyl polysiloxane material from
within the internal surface of the veneer (Figure 24) and to further position it onto the subs-
trate (Figure 25). After a few minutes, the veneer is removed carefully and evaluated for
442
points of rupture of the low viscosity material in contact with the veneer. Articulating paper
may also be used to locate the point of misadaptation. However, stains associated throu-
gh the use of the carbon paper are thereby created on the internal surface of the veneer,
which may be difficult to remove.
Interference sites should be removed from the substrate with coarse-grained alu-
minum oxide discs (Sof-Lex Pop-On®, 3M ESPE, USA) or diamond points in the case of
composite resin finishing (F series, KG®, Brazil). Intervention on the substrate is always
recommended, ceramic presents a low tenacity being that it is a relatively thin restoration,
which may propitiate cracks or even fractures. After this minor adjustment on the substra-
te, cementation is performed (Figures 26a and b). Currently, in order to minimize or even
to solve such a problem, ceramic materials have undergone structural changes such as
the addition of leucite and lithium disilicate described in Chapter 7.49
Figure 22. Analysis at rest revealing discrepancies between the central and lateral incisors (a). Initial smile. Presence of crowding, poor restorations, darkened teeth and gingival contour discrepancy (b).
Figure 23. Ceramic veneers placed on the working model.
Figure 24. The veneer presented misadaptation, requiring adjustment for proper adaptation. For this purpose, a low-viscosity PVS material was dispensed onto the inner surface of the veneer and
subsequently positioned onto the substrate.
Figure 25. After a few minutes, the veneer was removed with great care and rupture points of the low-viscosity PVS material were observed in contact with the veneer.
Figure 26. Note that after rehabilitation, the condition at rest is adequate and with the dominance of the centrals over the laterals (a). Final smile (b).
443
It is common for the partial seating of the ceramic veneer to be the result of excess
of the resin used for the provisional luting which accumulates on the remaining substrate.
Hence, the use of aluminum oxide impregnated disks at low speed is an excellent choice
for removal of these remnants of resin or cement used during the provisional stage. The
safest way for the substrate, but not so much for the technique is through the usage of
scalpel blades, by only promoting the removal of resin cement, resin or adhesive portions.
However, this use should be carried out parsimoniously, taking care when handling to
avoid injuries in the gingiva or lips.
Small misadaptations and minute gaps observed in the placement of the ceramic
veneers on the working model and confirmed at the moment of the try-in are completely
possible to be resolved by the adhesive cementation.
However, great misadaptations compensated by thick layers of cement may imme-
diately influence the final result of a ceramic veneer37 as well as in the proper longevity of
its aesthetics and functional results. After all, the weakest link of an adhesive cementation
is the cement-restoration-tooth interface, and therefore, a thick cement film will present
volumetric polymerization shrinkage inherent to all resinous materials, which may create a
marginal opening or loss of its ability to seal.47 SEM examinations demonstrate wear of the
luting agent and a consequent loss of adhesion, producing small marginal defects.47 The-
se defects, at times clinically imperceptible, may maintain the veneers functionally stable,
yet yield peripheral staining, causing a considerable aesthetic compromise, which favors
the infiltration of microorganisms and the development of caries.
FRACTURES DURING THE TRY-IN STEP

From this moment on, any manipulation of ceramic parts must be carried out within a
plastic container of a medium or large size and of a reasonable depth. Sometimes, exces-
sive confidence or uncautious manipulation by the professional can lead to the unintentional
dropping of the restorations and cause them to fracture, especially with feldspathic ceramic
or leucite-reinforced restorations (Figure 27). Even though it may seem strange during the
clinical moment, this preventive maneuver should be followed from the moment of the try-in
of the veneers on the stone model, to the try-in within the patient’s mouth, during the patient
evaluation in front of the mirror, until the cementation step, always positioned on the patient’s
body in clinical stages or having the patients themselves holding the container under their
chin, while evaluating the result of the try-in in a mirror.
In relation to the try-in and aiming for best aesthetic results, before the cementation
of the veneers, it is essential to carry out the try-in as described in Chapter 12. The try-in
pastes, accompanying resin cements, allow for both the dentist and the patient to evaluate
the shade of the ceramic veneer, predicting the final aesthetics and granting predictability to
the result,3,64 besides making it possible to perform small adjustments in the shade of those
cases along with substrates with different values and chromas.
However, because of the similarity of the try-in paste and resin cement syringes, which
sometimes, depending upon the trademark, is distinguished only by the color of the cover,
the clinician must be careful not to perform the try-in of the veneers with resin cement. If this
occurs, the resin cement will probably polymerize by the activation of the reflector light and
444
generate a lot of difficulty for the removal of the veneer. As a consequence, the thin ceramic
veneers may fracture, due to their minimal thickness. Thus, prior to the onset of the clinical
activity, it is suggested that the try-in pastes are available on the service desk and the resin
cements be deliberately stored (Figures 27 to 30).
Figure 30.
Figure 27. At the moment of try-in, the veneer carellesly fell and fractured. The fragments were positioned, but due to the mismatch of the fragments it was decided to replace it.
Figure 28.Initial intraoral view (a). Inadvertently, the color of the try-in veneers was carried out with resin cement (B). Due to the similarity of the try-in and resin cement syringes, a mistake has occurred,
which led to the polymerization of the cement by the operatory light itself.
Figure 29a-f. After careful removal, it was possible to observe the light-curing resin cement and the ceramic veneer from various photographic angles.
Figure 30. View after the shade evaluation with the Medium value try-in paste of the cement (Variolink Veneer®, Ivoclar Vivadent, Liechtenstein).
445
Furthermore, the similarity between homologous veneers like, for example, lateral
incisors, principally premolar veneers without preparation, due to a lack of clinical attention,
may generate an exchange at the time of the try-in, causing fracture by the resulting phy-
sical resistance. It is suggested that the veneers are positioned on the working model for
the future try-in. All things considered, the placement of the veneers on the substrate must
still be carried out with light finger pressure, keeping in mind that this set is extremely fragile
before being cemented. Remember that uniform fractures, if any, allow for correction as
long as the patient is informed in advance and accepts the proposed procedure.
After evaluation, adjustments and provisional approval of the result by the patient, the
ceramic surfaces “contaminated” by the try-in products aong with the substrate should be
thoroughly cleaned with water, abundantly, as the try-in step always results in some type
of chemical contamination of the surfaces, which hinders adhesion.
INADEQUATE TREATMENT OF CERAMIC VENEERS

In all cases presented in this book, only one veneer of a premolar displaced comple-
tely. Although the exact cause of this failure may vary, from case to case, the presence of
resin cement on the tooth suggests a specific failure in the treatment of the ceramic (eg,
incorrect etching of the ceramic).37
The longevity of ceramic veneers may be influenced by the variation of time and the
concentration of the hydrofluoric acid etching. Studies show that increased acid concen-
tration may lead to a significant weakening of the flexural strength of ceramic due to an in-
crease in microcracks, that may act as the sources of cracks. Furthermore, increasing the
etching time from 45 seconds to 90 seconds resulted in an increased surface roughness
from the etching2 (see micrographs in Chapter 12).
Total displacement of the veneer post-cementation involves a careful inspection of
the adjustment, and the performance of a new bonding, through the classic cementation
protocol described in Chapter 12. However, if cracks, chipping or misadaptations are de-
tected, a new impression must be made and the new veneer fabricated.
INCORRECT CHEMICAL TREATMENT OF THE SUBSTRATE
Fractures at the interface with full recovery of the veneer associated with the perma-
nence of the film of the resin cement adhered to the ceramic restoration suggests a failure in
the chemical treatment performed on the substrate, whether during the etching step, or the
application of unsuitable adhesives. This failure occurs mainly in the cementation of ceramic
veneers on dentin. Such a situation is present in cases with gingival recession, extensive
conventional preparation or in combination with extensive Class IV and III restorations.
The combination of marginal integrity, the use of state of the art dental adhesives and
a thorough execution of cementation procedures may help to minimize or even prevent
adhesive failures, as well as post-operative sensitivity.62
However, in some situations, full crowns are indicated on teeth with large composite
resin restorations which require additional removal of tissue, yielding to preparations in
dentin, being less favorable to substrate adhesion than enamel.10,44,35
446
CONTAMINATION OF THE SUBSTRATE AND CERAMIC RESTORATION DURING
THE CEMENTATION STEP
The longevity of a ceramic veneer is influenced by a number of factors during the
cementation procedures, such as the structural properties of the ceramic after chemical
treatment, the chemical properties of the adhesive resin, and the cementation techni-
que itself, all of which promote the development of a successful adhesion.25 However,
contamination inhibits the formation of a stable chemical bond, caused by a reduction of
the adaptation of the restorative material to the dental surface.1,23 In that way, exposure
to moisture and contaminants from the oral cavity may lead to adhesive failure, resulting
in debonding of the veneers. Consequently, a place without ambient moisture and clean
substrates as well as the ceramic are essential to achieve stable, long-term bonds.
Some agents have been identified for reducing the bond strength between ceramic
cement and substrates like:
• saliva;
• blood;
• PVS materials; and
• stone model.
Yet, contamination by examination gloves does not seem to have any influence on
the ceramic strength.11,59
According to Aboush,1 contamination by saliva on the veneer ready for cementation
can reduce the bond strength from 29.2 +/- 4.5 MPa to 10.3 +/- 4.5 MPa. There are many
protocols for the removal of contamination by saliva, such as the use of organic solutions,
phosphoric acid and a silane reapplication.1,59 The variety of strategies for decontamination
is due to the variables between studies for the treatment of ceramic prior to contamination. In
that way, the protocol recommended by the Dentistry Team of ABO-GO is through abundant
rinsing with an air/water spray to be followed up by the reapplication of silane.22
POOR POSITIONING OF THE VENEER DURING CEMENTATION

Prepless ceramic veneers or “contact lenses” do not have an insertion axis, ie they
are positioned and cemented in a passive vestibule-palatal direction. Therefore, the ce-
mentation step is very critical and deserves extra care in the positioning of the veneer and
subsequent light curing. This is due to the fact, that in cases of multiple veneers, a small
error in the positioning of the first veneer during cementation consequently leads to con-
secutive errors with the remaining veneers.
For the cementation protocol with several veneers (Chapter 12), it is suggested, after
the positioning of the first veneer (central incisor) with cement on the substrate, to remove
the excess with a brush and subsequently position the medially adjacent veneer without
cement, to check the exact positioning of the veneer to be polymerized. After confirming
the proper placement, the veneer without cement is removed and light curing takes place.
Remember that the inadequate removal of excess may inadvertently cause the bonding of
a veneer placed without cement.
The solution for improperly cemented veneers is dependent upon the size of the error
and its consequences. In some situations, it is imperceptible to the patient and therefore
447
our attention should not be called to the problem, because the harmonic rehabilitation set is
more important than unnecessary adjustments, with the inherent risks accompanied by the
grinding and polishing of ceramics within the mouth. In other situations, a small adjustment
with a diamond point (F or FF series, KG®, Brazil) and the subsequent polishing with the
proper abrasive rubbers for ceramics (Porcelain Veneer Polishing Kit® or Porcelain Veneer
Figure 33.
Figure 32 b. Figure 34.
Figure 31. Initial smile with shorter, yellowish teeth (a) and initial intraoral photograph (b).
Figure 32. Note that tooth #11 was cemented with a slight inclination.
Figure 33. A diamond tapered point is used to correct the inclination caused by improper positioning.
Figure 34. Appropriate polishing kit for ceramics (Porcelain Veneer Polishing Kit® or Porcelain Veneer Kit®, Shofu, Japan).
448
Kit®, Shofu, Japan) may provide an immediate solution for the case. However, some cases
obligatorily require replacement.
In the case presented (Figures 31 to 36), the immediate procedure was to make an
adjustment utilizing a diamond point and the subsequent polishing with rubbers. However, a
decrease in value was observed, therefore the veneer should be replaced in the near future.
Figure 35a-c. Abrasive rubbers were utilized in descending order of abrasivity.

Figure 36. Final intraoral photograph after polishing with the polishing kit (a). Final smile (b). Observe that after reduction, the veneer of tooth #11 presented a lower value and therefore obligatorily will
necessitate replacement in the near future.
449
POOR POLYMERIZATION
Commercially available cements for the cementation of ceramic veneers are usually
light cured by visible light or dual, depending on the opacity of the ceramic system.As des-
cribed in Chapter 11 and as a final suggestion from the authors, the major advantages of
light cured cements are their superior color stability and working time when compared with
chemically activated and dual-curing cements.
Apart from ease of use, light cured cements utilized for the cementation of ceramic
veneers, the additional advantage of not possessing amine within its composition as a
chemical initiator, which could cause discoloration of the material over the years.61
The literature shows that factors such as the type, thickness, color, and opacity of
the ceramic,5,52,56,39 type of curing, curing mode and light intensity32,43 may affect the poly-
merization of the resin cements.
Many times in severely discolored teeth, we were obligated to make use of opa-
que ceramics, which could have affected the light curing of the luting agent. According
to Chan & Boyer,17 for the cementation of extremely opaque ceramics which exhibit
a thickness greater than 2.0 mm, the use of dual-curing resin cements, for achieving
complete polymerization is suggested. The alternative being the light activation protocol
of 120 seconds.
The protocol for polymerization of translucent ceramic veneers and with a thickness
of up to 2.0 mm should be 60 seconds. Such a protocol aims to avoid incomplete poly-
merization of the light-cured resin cements, which would result in a low degree of con-
version and a large amount of residual monomers, may adversely affect the mechanical
properties as well as increase water sorption and solubility.14,41,56
As previously disclosed and as mentioned in Chapter 12, the authors suggest the
use of high-performance curing lights (eg, Blue Phase®, Ivoclar Vivadent, Liechtenstein),
which do not generate doubts about the conversion process and rule out the incorpo-
ration of a negative variable when utilizing veneers exactly at the end of the rehabilitation
process.
FRACTURES DURING THE CEMENTATION STEP

At the moment of cementation itself, one may encounter challenging situations, such
as a fracture in the cervical third (Figures 37 to 45).These fractures can usually be associa-
ted to their minimal thickness, pressure on the ceramic veneer during cementation, a misfit
not perceived during the try-in phase, as well as aggressive removal of the retraction cord.
However, the presence of a fracture is not by itself a failure. After all, strategies such
as repairing and polishing are available for its restoration. The rehabilitating alternatives are
primarily selected according to the extent and location of the fracture. In situations where
the surface of the fracture may not be polished, or the fracture is located in an area of func-
tional stress, which does not allow for its proper repair with composite resin, the restoration
should be classified as a failure and hence be replaced.
450
POLISHING
Fractures that do not interfere with the aesthetic results may be maintained and polished. This lack of interference with
the aesthetics is generally associated with situations which include small fractures of translucent ceramic veneers on clear
substrates (teeth after bleaching). However, there is the requirement of maintaining a smooth and polished surface so that
the appearance of the vitality of the ceramics is maintained as well as guarding against accumulation of plaque occurring
and food retention,20,30 mechanical irritation of the periodontium31 and reduction of the strength of the restoration.9
Accordingly, the surface abrasiveness of the ceramics should be minimized by the intraoral finishing and polishing
techniques, to achieve improved smoothness and the resulting biocompatibility. Remember that all finishing and polishing
intraoral strategies described in the literature are compared to the “gold standard” represented by glaze firing. This, in turn,
is a type of surface treatment known as over-glazing or extrinsic glazing, originating from the application of a clear porcelain
liquid during the laboratory phase, which is capable of producing smoother and denser surfaces.58
Investigations by Haywood & cols.29 and studies of Wiley63 have found that intraoral porcelain polishing with abrasive
tips may match or exceed the smoothness of the glazed porcelain. Thus, the ABO-GO Dentistry Team protocol includes
the use of the appropriate ceramic polishing kits (Porcelain Veneer Polishing Kit® or Porcelain Veneer Kit®, Shofu, Japan).
Raimondo & cols.51 observed that Shofu® rubbers are an efficient system for the finishing and polishing of ceramics
when used in conjunction with a polishing slurry containing a fine particulate diamond paste or extrafine pumice. Therefore,
we recommend the use of felt disks as an apppropriate vehicle for the polishing paste or extra-fine pumice.15
However, it should be understood that the proper process of finishing and polishing will not improve the results of an
inadequate preparation shape, misleading selection of restorative material nor inefficiency or inconsistency in the cemen-
tation protocol.
Figure 37. Figure 39b. Figure 40.
Figure 37. Initial photograph of the face.

Figure 38. Initial smile revealing short, naturally yellowish teeth with small diastemata.
Figure 39a-b. Ceramic veneers made from feldspar ceramic.
Figure 40. Fracture has occurred in the cervical third during the cementation due to the minimal thickness and the brittleness of the ceramic.
451
Figure 41e. Figure 42.
Figure 43.
Figure 41. After careful analysis the possibility of the cementation and polishing of the fractured veneer was defined. Points of Porcelain Veneer Polishing Kit® (Shofu, Japan) (a). Utilizing abrasive rubbers
of decreasing abrasivity (b-e).
Figure 42. Final appearance after polishing.
Figure 43. Final smile.
452
Figure 44.
Figure 45.
Figure 44. Face demonstrating naturalness.

Figure 45. Face in harmony. Responsible ceramist: Leonardo Bocabella.
453
REPAIR
Removing a ceramic veneer involves considerable effort, patient discomfort, time
and operational costs. A feasible option is the intraoral repair of the ceramic restoration,
even if it is a temporary solution, being that it is clinically reasonable and at times a con-
servative solution, to avoid the removal of healthy dental tissue. In addition, it prevents
such disadvantages as the removal of the restoration, maintenance of the function and
prevention of the accumulation of microorganisms on the fractured surface.
There are two types of repair.
• Replace the fractured area with composite resin (Figure 46)

The success of repair is largely dependent upon the strength and durability of the
bond between the repair material and the ceramic. There are various surface treatments
which mechanically or chemically increase bond strength such as etching with hydrofluoric
acid (HF), phosphoric acid, abrasive particles of aluminum oxide or silicatization (CoJet
System®, 3M ESPE, USA), creating roughness with diamond points and the application
of silane primers. In addition, chemical bonding may be obtained by a silane coupling
agent.40
In front of the arsenal of materials we have available in the routine practice, the
easiest way for repairing is the etching of the ceramic surface through the use of hydro-
fluoric acid for the appropriate amount of time and depending upon the ceramic system
or sandblasting with aluminum oxide (50 μm/0.5 bar), to then be followed by a silane
coating and the insertion of the composite resin.34
• Recementation of the ceramic fragment (fractured fragment) with resin cement

An ideal protocol for etching a complex comprising tooth tissue and ceramic is scar-
ce, however Saracoglu & cols.53 revealed that the surface contamination of enamel or
dentin with HF acid gel affected the bond strength of composite repair.
Therefore, the protocol of recementation of the ceramic restoration should be to
confer the strength of the attached portion and the connection between the ceramic
restoration and the attached portion. As to the fragment, the ceramic surface should
be etched with hydrofluoric acid for the appropriate time, dependent upon the ceramic
system or sandblasted with aluminum oxide (50 μm/0.5 bar), followed by a silane coa-
ting and then once again be cemented with resin cement. The fractured ceramic edges
must be roughened, both on the substrate and the attached portion, followed by the
hybridization steps of the remaining substrate, as outlined in Chapter 10.
REPLACEMENT
Replacement should always be the first option and for that, extended clinical chairsi-
de time for the anesthesia, removal of the fractured ceramic veneer under water cooling,
impression taking along with provisionalization steps are required (Figure 47).
Extra care should be dedicated towards minimizing removal of any tooth structure,
which becomes a challenge, since in cases with a clear substrate the shade of the ce-
ramic and the substrate should be matching. Therefore, the suggestion is to remove the
454
Figure 46. Initial smile exhibiting discrepancy of the gingival contour and lack of dominance of the centrals (a). Final smile (b). Two years after cementation, the patient presented a cohesive fracture by an
external stimulus (c). Etching of the ceramic surface with hydrofluoric acid (d). Phosphoric acid etching of dental enamel followed by silane coating (e), and insertion of a composite resin (f-g).
entire superficial portion with diamond points and, when approaching the substrate, use
#12 scalpel blades and abrasive discs, in order to minimize the loss of the healthy tooth
structure.
455
Figure 47. Initial gingival smile, demonstrating an approximate 3mm band of mucosa (a); Initial intraoral view (b); Ceramic veneers on the stone model (c);Ceramic veneers cemented (d); After three years,
ceramic veneer of tooth 11 was repaired with a composite resin after a fracture from mechanical trauma (e); After morphological adaptation of the composite resin repair, a canine to canine impression
was taken utilizing clear silicone for the copying of the shape and subsequent production of the provisional after complete removal of the fractured veneer (f-g); Removal of ceramic veneer with a
diamond point (h); Aspect after complete removal of the fractured veneer (i); After impression taking a spot-etch was performed (j); Application of adhesive (k); Insertion of resin composite inside the clear
guide (l); Placement of the assembly within the mouth, light curing and guide removal. Observe the appearance after the removal of the guide (m); Immediate polishing of the provisional (n); Result after
the cementation of the ceramic veneer (o).
456
Figure 47o.
457
STAINING OF EDGES AFTER CEMENTATION
After-cementation staining is most common in situations utilizing very opaque resin
cements (p. ex.: White Opaque, RelyX Veneer®, 3M ESPE, USA) associated with irregular
surfaces caused by areas of insufficient preparation and, consequently, exhibiting a diffe-
rent cement thickness. Such situations could be prevented with the use of the try-in paste
as well as through the evaluation of the marginal thickness; however, and as described
in Chapter 11, the try-in shade corresponding to opaque and to the high value cements
does not exactly match the shade obtained after cementation and does not effectively
characterize as the means of prevention for this failure.
According to Hajtó & Marinescu,27 veneers may present ceramic areas of variable
thickness which may create aesthetic problems. These problems are difficult to be cor-
rected during cementation, what is more, they will also be clearly visible to the patient.
Therefore, ideally a uniform and sufficient reduction of the tooth, not to be measured from
the original surface of the tooth, but rather, the result of the diagnostic wax-up. The use
of silicone guides is also a predictable technique and should be used in all veneer cases.
In situations with prepless veneers, the ceramist must maintain a standard ceramic
thickness, respecting the slopes of the dental element to be restored.
In both restorative techniques with ceramic veneers, with or without tooth prepa-
ration, one should avoid or limit using very opaque cements, to prevent complications
related to color, especially because one can not correct errors within the range of the resin
cement shades, but rather use it as a strategy for complex situations.
Another frequent situation in relation to the staining of the edges is related to the
removal technique of cement excesses, during cementation. As described in Chapter 12,
the authors suggest the removal of excess nonpolymerized resin cement with brushes
rather than utilizing the traditional of “tack cure” technique. The latter promotes the for-
mation of microscopic gaps along the cementation margin, enough for microleakage and
the incorporation of pigments that promote staining over time as well as the consequent
impairment of the long-term aesthetic result, promised at the initiation of the treatment
(Figure 48).
Yet, excesses of the applied adhesive system on enamel may also adversely in-
fluence the bond strength and produce staining. In Figure 49, note that immediately after
cementation there was no staining of the distal surface of tooth #11; however, after a few
days it was observed that the staining could be a consequence of the volume of the adhe-
sive system initially applied and that had been degraded, chemically and/or physically,
influencing the longevity of the aesthetic results. Therefore, preference is given to those
adhesives with adequate wettability and, after the application of the adhesive system, air
jets are applied.
458
Figure 49c.
Figure 48. Initial smile revealing small teeth, exhibition of more than 3.0 mm of gingiva, gingival darkening by melanin, presence of defective composite restorations and thick lips (a). Initial intraoral view
(b). Result immediately after cementation. Notice the presence of a dark stain in the mesial cervical third and, below, a small opaque spot. It is believed that the opacity is a defect (bubble) in the ceramic
matrix and that discoloration was caused by the premature removal of the retraction cord (c). Weeks after the cementation an equilibrium along the gingival margin was observed (d-e), however it was
decided to replace the veneer.
Figure 49. Initial smile with the presence of large diastema between the incisors (a). Result immediately after cementation, extremely natural (b). After 6 months, an observation of the presence of a dark
stain on the distal aspect of the veneer of tooth #11. After removal, a thick film left by the adhesive was observed (c).
459
RECURRENT CARIES
FAILURES IN THE
MAINTENANCE
Patients exhibiting a high risk of caries do not respond well to treatment because of
the high incidence of secondary caries, especially if the margins of the preparations are
located in dentin.33,46
Therefore, it is essential that the cementation margins are restricted to enamel 28,42
and are composite-free,26,57 because the partial adhesion to dentin or a composite and
the presence of high occlusal loads during static and dynamic occlusion increase the sus-
ceptibility of the ceramic to fracture.57 Furthermore, for these patients, rehabilitation with
ceramic veneers should only be considered if monitoring and prevention measures have
been previously established to avoid early recurrence of caries.65
Microleakage may be associated to several factors such as the misadaptation of the
ceramic veneer, a thick layer of adhesive, removal of excess cement by the “tack cure”
technique and compensations creating a thick line of cementation. In addition, the poly-
merization shrinkage inherent to luting composites may produce stress concentrations at
the application interface of the adhesive and generate small cracks, staining and hence
microleakage.
GINGIVAL ALTERATIONS
A protocol failure may culminate in follow-up appointments for maintenance due to
gingival alterations. This situation becomes exacerbated in patients with inadequate oral
hygiene.19 The most common situations for these gingival alterations are the presence of
resin cement or remnants of retraction cords within the sulcus and an excessively over-
contoured emergence profile.
Often in an attempt to remove subgingival excesses or retraction cords trapped
along the margin of cementation and improve the recontouring of the marginal convexity
in the gingival third after cementation, the glazed ceramic layer is removed by the clinician,
causing the surface to be rougher and open to plaque accumulation; that is, the point of
triggering for gingival alterations. Thus, it is essential, wherever possible, to maintain the
cementation margins of ceramic veneers at the supragingival levels, avoid recontouring
with diamond points after cementation and when necessary, utilize the appropriate intrao-
ral finishing and polishing kits specifically designed for ceramics.
Aesthetic problems may occur by the absence of papilla in cases of diastema closu-
re (see Chapter 6). Such a situation occurs from the distance between the bone crest and
the contact point being greater than 6 mm, which generates a black triangle, unfavorable
to aesthetic finishing. The strategic solution is to remove the veneers involving the dias-
tema, by carrying out a subgingival preparation and hence restoring the point of contact
more apically, which promotes a distance between the bone crest and the contact point of
at least 5 mm, beyond the natural aesthetic aspect, for the restablishment of the proximal
emergence profile.
460
BRUXISM
Ceramic veneers are brittle and cohesive failures may result from deleterious external
stimuli inappropriate to the teeth (eg, the opening of a bottle or the cutting of a ketchup
sachet with the teeth, hitting against any object and/or person) or through occlusal forces.
The occlusal forces refer to bruxism or activities similar to bruxism. However, patients
with functional problems should be treated, and their function, restored and protected prior
to the preparation of the veneers, as described in section 5.4.8
Several types of treatment, such as the use of occlusal splints and botulinum toxin
have been reported in the literature for bruxism, though there is no consensus on the best
option.36,60 The protocol adopted by the ABO-GO Dentistry Team for the control of bruxism
is through the use of orthotics or occlusal splints while sleeping and even during daytime
activities, such as weightlifting or extreme sports, which impose psychological and physi-
cal pressure on said practitioners.
This rigid acrylic splint should preferably be prepared with the help of models assem-
bled in a central relationship which possesses an anatomy capable of producing a classi-
cal canine guidance and consequent posterior disocclusion during excursive movements
of the mandible.
Fractures may be treated as described above, by means of a composite resin repair
and its subsequent replacement, always with the focus on early functional recovery (Figure
50).
Figure 50. Gingival smile, extremely worn teeth and disharmony (a-d). Result after periodontal surgery and the cementation of veneers (e-f). One day after cementation, the patient presented chipping of
tooth #12, incisal fracture of tooth #13 and extensive fracture of tooth #11, with fragment recovery (g-h). Result after repair of #13, polishing of #12, and recementation of the fragment of #11 (i-j). Final
smile 4 years after repairs and continuous use of the splint.
461
Figure 50k.
462
POSTOPERATIVE SENSITIVITY
Postoperative sensitivity is among the most inconvenient failures, generally asso-
ciated with mistakes during bonding procedures or technically mislead preparations. The
sensitivity may be present in preparations involving dentin and in this manner we must be
aware of the adhesive possibilities available in the dental market.
Among the adhesive strategies, described in Chapter 10, for preparations with den-
tin, we have: Option #1 - Utilizing a 3-step total-etching system; Option #2 - Utilizing a
self-etching system with selective enamel etching; and Option #3 - Use of a multimode
adhesive with the selective enamel etching, being cautious with respect to the thickness
and the shade of the prepless veneers.
In these three situations, the goal is to equilibrate the depth created by the acid in
the dentinal tubules by filling them with adhesive; thereby preventing empty areas where
post-operative sensitivity occurs. In the first option, the exposed dentin should not be
etched for more than 15 seconds, as by the established protocol and widely discussed
in the literature.
Despite the obvious, technically, it is imperative to define that each and every tooth
preparation be accomplished under refrigeraion with a copious amount of water, to avoid
severe heating and damage, sometimes irreversible to the dentinopulpar complex. The
clinical moment of unrefrigerated intervention is restricted only and solely to the refinement
of the preparation with a multiplier along with polishing of the substrate; however, always
accompanied by air cooling applied with a triple syringe.
CRACKS AFTER CEMENTATION
Post-cementation cracks are visible fracture lines = without separation of the ceramic
restorations from the tooth or cement. These failures can occur at an earlier stage in a
ceramic veneer without any progression over the years.37
The formation of these cracks is a problem caused by the rigidity of the ceramic
material,6,45 insufficient cleaning of the internal surface of the ceramic, insufficient thickness
of the preparation, polymerization shrinkage of the luting composite, forced seating of
the veneers during the cementation and the presence of parafunction without the use of
occlusal splints.
Post-adhesive cracks are problematic because there are not any procedure that can
treat this problem. If tolerated by the patient, these imperfections nevertheless should be
monitored, although no specific intervention should be recommended. The patient should
be informed that the formation of cracks do not constitute a risk to the remaining tooth
structure and that its deliberate replacement makes the procedure poorly conservative.
463
Ceramic veneers have demonstrated long-term success and have proven to be one
CONCLUSION
of the most successful treatment modalities of modern dentistry. The few difficulties may
be eliminated and circumvented if the dentist pays close attention to every detail of the
protocol. The development of new products and materials will bring long-term success,
provided that the principles used are based on scientific evidence.13
• Always manipulate veneers in a plastic container with considerable depth
TIPS
• Analyze the adaptation of the veneers on the stone model in advance
• Take pictures of the veneers individually to check for cracks or bubbles
• Evaluate the clinical adaptation of the veneers for preliminary adjustments
• Always try-in and photograph the veneers with especific pastes for approval of the
results by the patient
• Always etch the veneers and substrates individually
• If using a retraction cord, always repack it carefully into the sulcus after rinsing the
phosphoric acid and drying the substrate
• Dispense the cement homogeneously inside the veneer
• Always remove excess cement with a brush
• Always place the adjacent veneer during cementation
• Maintain light finger pressure on the veneers while curing
• Remove the retraction cords with a Sofia spatula after cementation, making sure of
its complete removal
• Fabricate the occlusal splints for controling bruxism immediately after cementation
• Schedule follow-up appointments for removal of the excess and polishing in the
following days
• Show “initial and final” photos to the patient
• Avoid carrying out morphological changes before 2 weeks
464
1. Aboush YE. Removing saliva contamination from porcelain veneers before bonding. J Prosthet Dent. 1998;80(6):649-53.
REFERENCES
2. Addison O, Marquis PM, Fleming GJP. The impact of hydrofluoric acid surface treatments on the performance of a porcelain
laminate restorative material. Dent Mater. 2007;23(4):461-8.
3. ALGhazali N, Laukner J, Burnside G, Jarad FD, Smith PW, Preston AJ. An investigationin to the effect of try-in pastes,uncu-
redand cured resin cements on the overall color of ceramic veneer restorations: an in vitro study. J Dent. 2010;38(2):e78-86.
4. Alhekeir DF, Al-Sarhan RA, Al Mashaan AF. Porcelain laminate veneers: clinical survey for evaluation of failure. Saudi Dent J.
2014;26(2):63-7.
5. Archegas LR, de Menezes Caldas DB, Rached RN, Soares P, Souza EM. Effect of ceramic veneer opacity and exposure
time on the polymerization efficiency of resin cements. Oper Dent. 2012;37(3):281-9.
6. Baran G, Boberick K, McCool J. Fatigue of restorative materials. Crit Rev Oral Biol Med. 2001;12:350-60.
7. Barghi N, Berry TG. Post-bonding crack formation in porcelain veneers. J Esthet Dent. 1997;9(2):51-4.
8. Beier US, Dhima M, Koka S, Salinas TJ, Dumfahrt H. Comparison of two different veneer preparation designs in vital teeth.
Quintessence Int. 2012;43(10):835-9.
9. Bessing C, Wiktorsson A. Comparison of two different methods of polishing porcelain. Scand J Dent Res. 1983;91(6):482-7.
10. Breschi L, Mazzoni A, Ruggeri A, Cadenaro M, Di Lenarda R, De Stefano DE. Dental adhesion review: aging and stability of
the bonded interface. Dent Mater. 2008;24:90-101.
11. Burke FJ, Main JR, Watts DC. Glove contamination of etched porcelain surfaces and bond strength to enamel. Am J Dent.
1996;9(1):40-2.
12. Calamia JR. The current status of etched porcelain veneer restorations. J Philipp Dent Assoc. 1996;47(4):35-41.
13. Calamia JR, Calamia CS. Porcelain laminate veneers: reasons for 25 years of success. Dent Clin North Am. 2007;51(2):399-
417, ix.
14. Calheiros FC, Daronch M, Rueggeberg FA, Braga RR. Degree of conversion and mechanical properties of a BisGMA:
TEGDMA composite as a function of the applied radiant exposure. Journal of Biomedical Materials Research. Part B, Applied
Biomaterials. 2008;84(2):503-9.
15. Camacho GB, Vinha D, Panzeri H, Nonaka T, Gonçalves M. Surface roughness of a dental ceramic after polishing with
different vehicles and diamond pastes. Braz Dent J. 2006;17(3):191-4.
16. Castelnuovo J, Tjan AH, Phillips K, Nicholls JI, Kois JC. Fracture load and mode of failure of ceramis veneers with different
preparations. J Prostet Dent. 2000;83:171-80.
17. Chan KC, Boyer DB. Curing light-activated composite cement through porcelain. J Dent Res. 1989;68(3):476-80.
18. Cherukara GP, Seymour KG, Samarawickrama DY, Zou L. A study into the variations in the labial reduction of teeth prepared
to receive porcelain veneers: a comparison of three clinical techniques. Dent. J. 2002;192(7):401-4.
19. Christensen GJ, Christensen RP. Clinical observations of porcelain veneers: a three-year report. J Esthet Dent. 1991;3(5):174-9.
20. Clayton JA, Green E. Roughness of pontic materials and dental plaque. J Prosthet Dent. 1970;23(4):407-11.
21. D’Arcangelo C1, Vanini L, Prosperi GD, Di Bussolo G, De Angelis F, D’Amario M, et al. The influence of adhesive thickness
on the microtensile bond strength of three adhesive systems. J Adhes Dent. 2009;11(2):109-15.
22. Della Bona A, Northeast SE. Shear bond strength of resin bonded ceramic after different try-in procedures. J Dent.
1994;22(2):103-7.
23. Duarte SJ, Lolato AL, de Freitas CR, Dinelli W. SEM analysis of internal adaptation of adhesive restorations after contamina-
tion with saliva. J Adhes Dent. 2005;7:51-6.
24. Dumfahrt H. Porcelain laminate veneers: a retrospective evaluation after 1 to 10 years of service: Part 1: Clinical procedure.
Int J Prosthodont. 1999;12(6):505-13.
25. El Zohairy AA, De Gee AJ, Hassan FM, Feilzer AJ. The effect of adhesives with various degrees of hydrophilicity on resin–ce-
ramic bond durability. Dent Mater. 2004;20:778-87.
26. Friedman MJ. A 15-year review of porcelain veneer failure: a clinician’s observations. Compend Contin Educ Dent.
1998;19:625-30.
27. Hajtó J1, Marinescu C. An aesthetic challenge: isolated areas of high translucency in laminate veneers. Eur J Esthet Dent.
2012;7(3):282-94.
28. Petridis HP1, Zekeridou A, Malliari M, Tortopidis D, Koidis P. Survival of ceramic veneers made of different materials after
a minimum follow-up period of five years: a systematic review and meta-analysis. Eur J Esthet Dent. 2012;7(12):138-52.
29. Haywood VB, Heymann HO, Scurria MS. Effects of water, speed, and experimentalinstrumentation on finishing and polishing
porcelain intra-orally. Dent Mater. 1989;5(3):185-8.
30. Jefferies SR, Barkmeier WW, Gwinnett AJ. Three composite finishing systems: a multisite in vitro evaluation. J Esthet Dent.
1992;4(6):181-5.
31. Jefferies SR. The art and science of abrasive finishing and polishing in restorative dentistry. Dent Clin North Am.
1998;42(4):613-27.
32. Jung H, Friedl KH, Hiller KA, Furch H, Bernhart S, Schmalz G. Polymerization efficiency of different photocuring units through
ceramic discs. Oper Dent. 2006;31(1):68-77.
33. Kidd EAM, Fejerskov O. What constitutes dental caries?: histopathology of carious enamel and dentin related to the action
of cariogenic biofilms. J Dent Res. 2004;83:35-8.
34. Kimmich M, Stappert CF. Intraoral treatment of veneering porcelain chipping of fixed dental restorations: a review and clinical
application. J Am Dent Assoc. 2013;144(1):31-44.
35. Kramer N, Lohbauer U, Frankenberger R. Adhesive luting of indirect restorations. Am J Dent. 2000;13:60-76.
36. Lavigne G, Kato T, Kolta A, Sessle B. Neurobiological mechanisms involved in sleep bruxism. Crit Rev Oral Biol Med.
2003;14(1):30-46.
37. Magne P, Belser U. Bonded porcelain restorations in the anterior dentition: a biomimetic approach. Carol Stream: Quintes-
sence; 2002.
38. Magne P, Douglas WH. Rationalization of aesthetic restorative dentistry based on biomimetics. J Esthet Dent. 1999;11(1):5-15.
39. Meng X, Yoshida K, Atsuta M. Influence of ceramic thickness on mechanical properties and polymer structure of dual-cured
resin luting agents. Dent Mater. 2008;24(5):594-9.
465
40. Mohamed FF, Finkelman M, Zandparsa R, Hirayama H, Kugel G. Effects of surface treatments and cement types on the bond
strength of porcelain-to-porcelain repair. J Prosthodont. 2014;27.
41. Ortengren U, Wellendorf H, Karlsson S, Ruyter IE. Water sorption and solubility of dental composites and identification of
monomers released in an aqueous environment. Journal of Oral Rehabilitation. 2001;28(12):1106-15.
42. Oztürk E, Bolay S. Survival of porcelain laminate veneers with different degrees of dentin exposure: 2-year clinical results. J
Adhes Dent. 2014;16(5):481-89.
43. Ozyesil AG, Usumez A, Gunduz B. The efficiency of different light sources to polymerize composite beneath a simulated
ceramic restoration. J Prosthet Dent. 2004;91(2):151-7.
44. Perdigão J. Dentin bonding-variables related to the clinical situation and the substrate treatment. Dent Mater. 2010;26:e24-
37.
45. Peumans M, Van Meerbeek B, Yoshida Y, Lambrechts P, Vanherle G. Porcelain veneers bonded to tooth structure: an ultra-
morphological FE-SEM examination of the adhesive interface. Dent Mater. 1999;15:105-19.
46. Peumans M, Kanumili P, De Munck J, Van Landuyt K, Lambrechts P, Van Meerbeek B. Clinical effectiveness of contemporary
adhesives: a systematic review of current clinical trials. Dent Mater. 2005;21(9):864-81.
47. Peumans M, Van Meerbeek B, Lambrechts P, Vanherle G. Porcelain veneers: a review of the literature. J Dent. 2000;28(3):163-
77.
48. Phark JH, Duarte S Jr, Kahn H, Blatz MB, Sadan A. Influence of contamination and cleaning on bond strength to modified
zirconia. Dent Mater. 2009;25(12):1541-50.
49. Phillips RW. Skinner Materiais Dentários. 9a ed. Rio de Janeiro: Guanabara Koogan; 1991.
50. Radz GM. Minimum thickness anterior porcelain restorations. Dent Clin North Am. 2011;55(2):353-70.
51. Raimondo RL Jr, Richardson JT, Wiedner B. Polished versus autoglazed dental porcelain. J Prosthet Dent. 1990;64(5):553-
7.
52. Rasetto FH, Driscoll CF, Prestipino V, Masri R, von Fraunhofer JA. Light transmission through all-ceramic dental materials: a
pilot study. J Prosthet Dent. 2004;91(5):441-6.
53. Saracoglu A, Ozcan M, Kumbuloglu O, Turkun M. Adhesion of resin composite to hydrofluoric acid-exposed enamel and
dentin in repair protocols. Oper Dent. 2011;36(5):545-53.
54. Scopin de Andrade OS, Romanini JC, Hirata R. Ultimate ceramic veneers: a laboratory-guided ultraconservative preparation
concept for maximun enamel preservation. Quintessence Dent Technol. 2012;35:29-42.
55. Soares CJ, da Silva NR, Fonseca RB. Influence of the feldspathic ceramic thickness and shade on the microhardness of
dual resin cement. Oper Dent. 2006;31(3):384-9.
56. Soares LE, Liporoni PC, Martin AA. The effect of soft-start polymerization by second generation LEDs on the degree of
conversion of resin composite. Operative Dentistry. 2007;32(2):160-6.
57. Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior dental aesthetics. J Am Dent Assoc.
2006;137(2):160-9.
58. Sulik WD, Plekavich EJ. Surface finishing of dental porcelain. J Prosthet Dent. 1981;46(2):217-21.
59. Swift B, Walls AW, McCabe JF. Porcelain veneers: the effects of contaminants and cleaning regimens on the bond strength
of porcelain to composite. Br Dent J. 1995;179(6):203-8.
60. Tan EK, Jankovic J. Treating severe bruxism with botulinum toxin. J Am Dent Assoc. 2000;131(2):211-6.
61. Tanoue N, Koishi Y, Atsuta M, Matsumura H. Properties of dual-curable luting composites polymerizedwith single and dual
curing modes. J Oral Rehab. 2003;30(10):1015-21.
62. Toati B, Miara P, Nathanson D. Aesthetic dentistry and ceramic restorations. New york: Martin Dunitz; 1999.
63. Wiley MG. Effects of porcelain on occluding surfaces of restored teeth. J Prosthet Dent. 1989;61(2):133-7.
64. Xing W, Jiang T, Ma X, Liang S, Wang Z, Sa Y, Wang Y. Evaluation of the aesthetic effect of resin cements and try-in pastes
on ceromer veneers. J Dent. 2010;38(2):e87-94.
65. Yoshiyama M, Tay Fr, Doi J, et al. Bonding of self-etching and total-etching adhesives to carious dentin. J Dent Res.
2002;81(8):556-60.
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Ceramic Veneers Contact Lenses and Fragments

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PAULACARDOSO & RAFAELDECURCIO

1st Edition, 2018

Título original: Facetas : lentes de contato e fragmentos cerâmicos.

1. Odontologia 2. Cerâmicas dentárias 3. Facetas dentárias 4. Lentes de contato I.

RAFAEL DE ALMEIDA DECURCIO

MARCUS VINÍCIUS N. M. DOS R. PERILLO DE FREITAS

TERENCE ROMANO TEIXEIRA

WILMAR PORFÍRIO DE OLIVEIRA

ANA PAULA RODRIGUES DE MAGALHÃES

AMIN DE MACEDO MAMEDE SULAIMEN

JOÃO CHRISTOVÃO PALMIERI FILHO

GUIDO CIRILO FERREIRA

ALTAMIRO FLÁVIO RIBEIRO PACHECO

JÚNIO S. ALMEIDA E SILVA

FERNANDA G. V. PALHARES SAKEMI

JULIANA NUNES ROLLA

RENATA GONDO MACHADO

LEANDRO DE CARVALHO CARDOSO

Luiz Narciso Baratieri

Paula Cardoso & Rafael Decurcio

Paula Cardoso & Rafael Decurcio

PAULA DE CARVALHO CARDOSO

Paula Cardoso & Rafael Decurcio

SECTION III. IMPLEMENTATION

SECTION IV. CEMENTATION

FACIAL REFERENCE LINES

Figure 1a. Figure 2b.

Figure 3a. Figure 3b. Figure 3c.

Figure 3d. Figure 3e.

Figure 4a. Figure 4b.

Figure 4d. Figure 4e.

Figure 6c. Figure 6d.

Figure 7a. Figure 7b. Figure 7c.

Figure 7d. Figure 7e.

PROPORTION OF THE THIRDS OF THE FACE

Figure 11a. Figure 11c. Figure 11d.

Figure 12b. Figure 12d. Figure 12e.

DISPLAY OF THE ANTERIOR TEETH

Figure 16a. Figure 16b. Figure 17.

Figure 18a. Figure 18b. Figure 18c.

Figure 18d. Figure 18e. Figure 18f.

FULL SMILE POSITION

Figure 21a. Figure 21b. Figure 21c.

Figure 22. Figure 23.

Figure 24a. Figure 24b.

Figure 24c. Figure 24d.

Figure 25a. Figure 25b.

Figure 26a. Figure 26b.

Figure 26c. Figure 26d.

Figure 27. Figure 28b.

Operative Dentistry – Ideal Dimensions

63 Lateral Width Canine Width 100% 75% 85%

Width of the Width of the

x1,33 x1,25 x1,33 x1,25

Width Length -1,0 -0,5 11,62 10,1 11,12

Final Value = 10,1

Figure 29a. Figure 29b.

Labial-palatal cross-sectional slices - Real size (1:1)

Figure 30e. Figure 30f.

Figure 30g. Figure 30h. Figure 30i.

Figure 30j. Figure 30k.

Table 2. Characteristics of the most commonly found tooth shapes.

SHAPE SQUARED OVOIDAL TRIANGULAR