PROSTHODONTICS
Noninvasive interdisciplinary treatment of a dischromic
partially worn dentition
Arturo Imbelloni, DMD/Roberto Iafrate, CDT/Cesare Luzi, DMD, MSc
According to the classic concepts of prosthodontics the treat-
ment of a patient presenting severely worn and dischromic
dentition would involve a complex and demolitive treatment
including periodontal surgery, endodontic therapy, posts and
cores, and crowns; nowadays these problems can be solved
with noninvasive procedures that allow preservation of dental
and periodontal tissues. This article describes the interdisciplin-
ary team approach (orthodontist, dental technician, prostho-
dontist) for the treatment of a patient showing attrition of the
mandibular incisors in a deep bite relationship, contraction of
the posterior sextants of both arches, diastemas in the anterior
region of the maxilla, and highly dischromic teeth. The gingival
Key words: adhesion enamel, bruxism, dental technology, dischromic dentition, minimally invasive dentistry, orthodontics,
prosthodontics, tooth wear
Patients affected by severely worn dentition often present with
extreme damage of their teeth, especially in the anterior quad-
rants. The vertical dimension of occlusion (VDO) may have
decreased, and supraeruption may have occurred. Conven-
tional therapies consist of extensive elective root canal treat-
ment, crown lengthening procedures, and full-crown coverage
of many teeth. However, this approach may be too aggressive,
considering that new techniques can provide clinicians with
more conservative solutions.
The key for the successful outcome of these cases is effi-
cient interdisciplinary communication, since all the disciplines
can share responsibility for a treatment plan based on a mutual
understanding of the factors involved.
The diagnostic wax-up gives the dental team a three-di-
mensional illustration of the project of a new smile, and the
mock-up allows full interchange of ideas among the clinicians,
294 QUINTESSENCE INTERNATIONAL | volume 50 • number 4 • April 2019
tissue levels and the tooth malposition were corrected by or-
thodontic therapy, the abraded and the healthy dischromic
teeth were restored with 20 additional veneers (the molars
were the only teeth not involved in the restorative phase);
tooth structure, tooth vitality, and bone level were maintained.
No provisional restorations were delivered and no anesthesia
was necessary either for tooth preparation or final impression.
A protocol is shown to treat in a conservative and comfortable
manner the structural and esthetic problems in a patient pre-
senting highly dischromic teeth, worn mandibular incisors, and
diastemas on the maxillary sextant. (Quintessence Int 2019;50:
294–304; doi: 10.3290/j.qi.a42171)
dental technician, and patient, ensuring satisfaction of all the
parties before the beginning of the treatment.
Thus far, orthodontics has been used mainly in young patients
and less frequently in adult patients; for the latter, careful planning
is mandatory in order to take advantage of all the potential bene-
fits that this specialty can offer to treat different clinical problems:
predictability is good when forces are correctly applied, periodon-
tal conditions are addressed, and oral hygiene is maintained.
The adhesive approach preserves more tooth structure and
avoids elective endodontic therapy. In addition, in the present
authors’ opinion, the esthetic outcome of teeth restored with
bonded porcelain restorations is superior to that achieved with
cemented crowns. Further, gingival tissues seem to interact
better with the margins of bonded veneers than with the mar-
gins of cemented crowns, resulting in less inflammation or dark
colorations.
 Imbelloni et al

1 2a

2b 2c

Fig 1 Preoperative intraoral view of the patient showing severe loss of healthy tooth structure.
Figs 2a to 2c Preoperative images of the patient presenting high discoloration of his teeth, diastemas of the maxillary anterior teeth, and
mandibular gingival display.

Veneers are one of the latest solutions employed to solve in a
conservative manner the reconstruction of compromised denti-
tions; they require careful handling, especially when tooth struc-
ture is not prepared as in the case of additive restorations. Feld-
spathic ceramic was the material used to treat the present patient,
since it has the best optical qualities and the strongest adhesion.
The above-mentioned approach allows treatment of patients
in a very conservative and comfortable way. The following are
the advantages in the treated case:
■ tooth structure was almost completely preserved (very
light odontoplasty was performed)
■ root canal treatments were avoided
■ bone was left intact (no crown lengthening procedure was
needed)
■ no provisional restorations were delivered since teeth were
left practically intact; hence, it was possible to make the
veneers without rushing and to have more try-in checks
without compromising the quality of life of the patient
■ no anesthesia was necessary for either tooth preparation or
final impression.
Case presentation
A 40-year-old man presented severe tooth wear of the mandib-
ular incisors, high discoloration of his teeth, diastemas of the
maxillary anterior teeth, and gingival display of the mandibular
sextant (Figs 1 and 2).
Several data were recorded to study the case: alginate
impressions, panoramic radiographs (Fig 3), periapical radio-
graphs, periodontal chart, and extraoral and intraoral photo-
graphs. The extraoral examination showed strong masticatory
muscles and good general symmetry. The intraoral examina-

QUINTESSENCE INTERNATIONAL | volume 50 • number 4 • April 2019 295

 PROSTHODONTICS
tion showed signs of tooth wear on the maxillary and mandib-
ular anterior sextants; this was more severe on the mandibular
incisors where approximately 50% of the clinical crown was lost
(Fig 1) with a consequent compensative eruption that caused
contact of the incisal edge with the maxillary palatal marginal
gingiva and gingival exposure at the smile analysis; in contrast,
posterior teeth did not show major signs of wear.
All teeth presented an unpleasant dyschromia, and the
maxillary anterior teeth presented diastemas and a few incisal
irregularities; a deep overbite was evident (Fig 4).
The examination of the study casts better underlined the
contraction of the posterior sextants on the frontal plane, the
Class I malocclusion with increased anterior overbite, and the
severely worn clinical crowns of the mandibular incisors that
were completely overlapped by the maxillary anteriors. The
diagnosis was attrition due to occlusal problems from a
restricted envelope of function.
The patient was informed that the reduction of the clinical
crown of the mandibular incisors was a sign of a functional
problem involving the entire masticatory system and that the
best treatment would be to make space for a restorative mater-
ial, expanding the maxillary arch and intruding the mandibular
incisors orthodontically, enhancing at the same time the occlu-
sal function and better preserving the reconstructed teeth;
hence, the incisal space created would be used to restore the
mandibular anterior teeth in a conservative manner to avoid
crown lengthening, root canal therapies, and crowns.
The patient also expressed the desire to improve the overall
appearance of his smile without cutting his teeth: to achieve this
goal 20 additional veneers (12 over the incisal and facial walls of
296 QUINTESSENCE INTERNATIONAL | volume 50 • number 4 • April 2019
Fig 3 The panoramic radiograph shows
signs of tooth wear of the mandibular
incisors, diastemas of the maxillary anterior
teeth, amalgam restorations on the maxillary
right second molar and right and left first
molars (teeth 17, 16, and 26), mandibular
right second molar (tooth 37) porcelain-
fused-to-metal (PFM) crown, implant at the
mandibular left first molar (36), and root
canal treated with metal post and core and
PFM crown mandibular right first molar
(tooth 46).
the anterior teeth, and eight over the facial walls of the premo-
lars) were proposed and accepted to improve the “white esthet-
ics,” while orthodontics would also improve the “pink esthetics.”
Orthodontic therapy
Slow controlled orthodontic tooth movement causes the entire
attachment apparatus to shift in unison with the tooth.1
The patient presented a Class I malocclusion with increased
anterior overbite and severe tooth wear of the mandibular inci-
sors; he was brachyfacial with a reduced vertical jaw relationship
and an anteriorly rotated mandibular position. The continuous
mechanical wear of the enamel surfaces over the years had
determined a progressive shortening of the clinical crowns of
the mandibular anterior teeth followed by passive eruption and
deepening of the bite. Several diastemas were present between
the maxillary anterior teeth. The palatal surfaces of the maxillary
incisors were slightly abraded, and impingement of the palatal
gingiva was present due to the deep overbite; the incisal tooth
structure of the mandibular incisors was compromised both
from a functional and an esthetic standpoint. The decision was
made to perform a preprosthetic orthodontic treatment with
the aim of opening the bite anteriorly in order to generate
enough space for the prosthodontist to restore the maxillary and
mandibular anterior teeth with a minimally invasive approach.
Orthodontic tooth movement has the advantage of remod-
eling the entire periodontium,2 therefore particular attention
was given not only to tooth alignment but also to adequate
positioning of the gingival margins. The decision was made to
perform minor intrusion of the maxillary sextant to avoid un-

4 5
Fig 4 A deep vertical overjet and severely dischromic teeth are
evident.
Fig 5 Orthodontic treatment achieved the intrusion of the anterior
sextants, generating sufficient interocclusal space for the anterior
restorations; meanwhile, the interproximal space distribution and the
gingival levels of the maxillary sextant were established.
Fig 6 Mock-up try-in stage: diastemas were closed and the shape
and color of the project were discussed with the patient.
pleasant final short incisor display at the smile3; major intrusion
was instead planned for the mandibular anterior segment.
Orthodontic treatment began with the bond-up of both
dental arches with fixed appliances and composite bite-raising
on the posterior mandibular molars in order to allow bracket
positioning in the mandibular arch. The maxillary arch was lev-
eled and aligned with a conventional straight-wire approach
and progressively stiffer super-elastic archwires, until a full size
rectangular 0.019 × 0.025” stainless steel archwire could be
inserted into all the brackets. Minor intrusion bends were per-
formed to accomplish final active intrusion of the maxillary
incisors. Stainless steel open-coils were used on the archwire to
finalize strategic anterior interdental spacing required by the
prosthodontist for consecutive indirect restorations (Fig 5).
A segmented approach was preferred for the mandibular arch
since absolute intrusion of the anterior segment was the goal.4,5
A beta-titanium 0.017 × 0.025” utility-shaped base-arch was
used during the first 6 months of treatment. Following active
intrusion and leveling of the curve of Spee, continuous arch-
wires were used to finalize the alignment.
The finishing phase started after 14 months of active treat-
ment and multistrand 0.018 × 0.025” archwires were inserted in
both arches and used in combination with maxillomandibular
elastics to achieve final intercuspation.
QUINTESSENCE INTERNATIONAL | volume 50 • number 4 • April 2019
Imbelloni et al
6
The patient was debonded after 19 months of treatment
and immediate Essix-type thermoplastic retainers were fabri-
cated for retention. The patient was referred back to the prosth-
odontist.
Orthodontic treatment is the least invasive procedure to
create room for prosthetic needs, correct occlusal problems, and
enhance the final esthetic outcome; in this patient, by intruding
the anterior sextants, the posterior teeth were not occlusally
restored because there was no need to increase the VDO.
Wax-up and mock-up
A wax-up was made6 and used to fabricate a removable in-
direct mock-up in the laboratory on an unaltered cast, to be
examined later intraorally by the clinician; this was later
duplicated in acrylic resin,7,8 through a silicone index that was
then tried-in and modified according to the dynamic esthet-
ics of the patient’s face: in that moment the authors trans-
ferred this information from the laboratory to the mouth to
achieve a realistic three-dimensional perception of the final
result (Fig 6).
A diagnostic wax-up can enhance the predictability of
treatment by modeling the desired result in wax before start-
ing therapy.
297
 PROSTHODONTICS
7 8
Fig 7 End of the orthodontic treatment.
Fig 8 Preparation of the teeth consisted only in the removal of major undercuts and sharp angles, so that these were left mainly intact.
Preparation/odontoplasty
Additional veneers are usually thinner than conventional
veneers since the clinician does not prepare the teeth but just
removes major undercuts and unsupported enamel edges, and
rounds sharp angles (Fig 7 and 8) in order to decrease the dan-
gerous concentration of tensile stresses that is a major cause of
structural failure of an adhesive prosthesis9; this way, enamel is
almost totally preserved to realize an optimal bond.
This was possible since occlusal space was created in different
ways: for the mandibular anterior teeth intruding the same sex-
tant, for the maxillary anterior teeth expanding the arch, and for
the mandibular premolars a light odontoplasty was performed
only on the maxillary buccal surface of the facial cusp; the space
created in such a conservative manner was gained in order to give
more room to the restorations in an area exposed to functional
load. The occlusal surface of the facial cusp of the same teeth was
not prepared but was covered with an extension of the veneers
that was later eliminated after cementation; its purpose was to
help the prosthodontist to position the restorations properly.
This procedure allowed two try-in appointments with a com-
fortable time sequence to verify both patient and clinician satis-
faction for the final outcome; in contrast, in case of prepared
conventional veneers the prosthodontist must deliver the final
restorations within a short time-span from the day of tooth
preparation, owing to the complex management of the provi-
sional phase.
Additional veneers either do not require tooth preparation
or require only a light odontoplasty, so that tooth structure can
be preserved; from the patient’s perspective, the absence of
“shots and drilling” makes the procedure much more pleasant
and acceptable.
298 QUINTESSENCE INTERNATIONAL | volume 50 • number 4 • April 2019
Impression
The final impression was taken without reflecting the gingival
marginal tissues since the authors decided there was no need
to place the margins of the restorations under the gingival level.
This was a major advantage for the patient, who was submitted
to a shorter and less traumatic procedure (no anesthesia).
A polyvinylsiloxane impression material (Aquasil, Dentsply)
was used with the one-step double-mix technique: an extra-
light body was applied with a syringe over the teeth while a
medium body was placed into a stock metal-tray.
Provisionals were not delivered since teeth had their origi-
nal structure preserved and the patient could maintain his nor-
mal lifestyle without risk of decementation of the provisionals.
Laboratory procedures
The data collected during the mock-up try-in were elaborated
by the clinician and the technician, then transferred to the mas-
ter casts that were mounted on a semi-adjustable articulator
(Mark II, Denar): alveolar casts were made of class 4 gypsum;
these were covered with a 0.02-mm platinum foil to realize a
structure that can support the feldspathic ceramic veneer in
the furnace during firing.
A disadvantage of this technique is that once the foil has been
removed it is impossible to bake the porcelain again; two major
advantages are the excellent marginal fit and esthetic result.
Today there are many good indirect restorative materials on
the market, such as feldspathic ceramic, lithium disilicate glass
ceramic, glass-infiltrated alumina porcelain, zirconia ceramic,
and composite resin. Among these, the first can be applied
using the platinum foil technique with two major advantages:

Fig 9 Porcelain baked on foil seems to have more translucency.
The surface details and refraction of the light can be seen.
It is always recommended to check the contact points on a separate
cast that has not been sectioned.
first, a very good bond to enamel; second, optimal translu-
cency, fluorescence, and color.
The principal difficulty of this case was to mask the strong
chroma of the teeth, even darker than A4–C4 of the Vita scale
(Vita Zahnfabrik), with 0.3- to 0.5-mm thick additional feld-
spathic ceramic veneers.
The present authors developed a stratification technique
they used in this case. It consists in mixing dentin (A1) and dif-
ferent opaque enamels (Willi Geller, Creation, Klema) and
applying it in very thin layers in a way that blocks out the gray
coming from the inside. Later, further layers of enamel were
stratified as in a conventional ceramic restoration. The layering
was done so that the light is scattered inside the porcelain to
produce an illusion of opalescence and fluorescence (Fig 9).
Before delivery, the veneers were airborne-particle abraded
with a 50-μm aluminum oxide powder.
Using feldspathic ceramic for additional veneers gives excel-
lent esthetic and bonding results, but it is technique sensitive.
Try-in
In case of additional veneers the try-in enables the clinician to
verify the path of insertion of each veneer and the presence of
any interference to its complete seating (Fig 10).
A soft silicone cup (Pro-Cup, Kerr) was used with a lightly
abrasive prophy paste without fluoride (Nupro Sensodyne Pol-
ish Paste, Dentsply) to clean the intact dental surfaces.
After this phase was completed, the lubricant gel and all
the contaminants were removed thoroughly from the ceramic
surface with 95% alcohol.
QUINTESSENCE INTERNATIONAL | volume 50 • number 4 • April 2019
Imbelloni et al
Only using this approach is it possible to do several tries-in
without the drawbacks due to the presence of the provisionals.
Cementation
Nowadays, three-step “etch and rinse” adhesives are the gold
standard for adhesive cementation.10
After checking the color with a water-soluble glycer-
in-based try-in paste (Variolink II Try-In Paste, Ivoclar Vivadent),
veneers were thoroughly rinsed with water, placed in 95% alco-
hol in an ultrasonic cleaner for 5 minutes, then dried out care-
fully; they were etched with a 9.6% hydrofluoric acid (Pulpdent)
for 60 seconds, profusely rinsed, dried again, and a 37% phos-
phoric acid gel (Scotchbond Etchant Gel, 3M Espe) was applied
for 2 minutes, profusely rinsed, then dried again; a universal
primer (Monobond Plus, Ivoclar Vivadent) was applied for 60
seconds, then dried with hot air flow for 2 minutes to improve
its coupling effect (the bond strength results are twice as high
as when no heating is used11); the veneers were positioned
under a protective shield, ready for cementation.
At the same time, the area was isolated, the outer layer of
the intact enamel tooth surface was cleaned with a soft silicone
cup (Pro-Cup) applying a lightly abrasive prophy paste without
fluoride (Nupro Sensodyne Polish Paste), then was roughened
with an airborne-particle abrasion system with spray (Rondo-
flex Plus 360, KaVo Dental), thoroughly rinsed, then etched
with 37% phosphoric acid gel (Scotchbond Etchant Gel) for
30 seconds, rinsed again for 30 seconds and air-dried gently; a
primer (Scotchbond Primer, 3M Espe) was brushed over the
tooth for 20 seconds and dried gently. A bonding resin (Scotch-
299
 PROSTHODONTICS
10a
Figs 10a and 10b Final try-in: a cheek retractor with an interocclusal stop was placed to protect the veneers, which are very fragile before
cementation.
11
Fig 11 Pre-restorative situation.
bond Adhesive, 3M Espe) was applied and aspirated but not
light cured, to avoid a premature polymerization that would
have prevented the correct sitting of the restoration.
An even mass of transparent dual-curing luting composite
base (Variolink II Transparent Base, Ivoclar Vivadent) was
applied on the veneers: it was not mixed with the catalyst in
order to extend the working time and avoid possible dischro-
mia due to the amines present in a catalyst.
Light curing was performed for 40 seconds on each side (pal-
atal, mesiobuccal, distobuccal, buccal) and 20 seconds on the
margins; glycerin gel (Glycerin Air Block, Enamel Plus Shiny, Mice-
rium) was applied over the margins and further light curing was
performed to complete the polymerization process of these areas.
A maxillary night-guard was delivered to protect teeth and
restorations from the adverse effects of uncontrolled nocturnal
parafunctional habits.
Cementation is a very delicate clinical phase in case of
veneers, and even more in case of additional veneers, since
they are very fragile before delivery; after cementation on
300 QUINTESSENCE INTERNATIONAL | volume 50 • number 4 • April 2019
10b
12
Fig 12 New design within the composition.
enamel, these restorations become very strong, in addition to
giving a beautiful esthetic outcome.
Finishing and polishing
Cementing 20 additional veneers was a long procedure, and
more time was necessary to adjust thoroughly the occlusion in
order to avoid premature fractures of the restorations.
A finishing-polishing kit was used to finish and polish occlu-
sal surfaces and restorative margins (Dr. Arturo Imbelloni Finish-
ing and Polishing Dialite kit K100658-1 for ceramic restorations,
Komet).
The finishing-polishing stage requires care by the clinician
in order to create the correct marginal adaptation and emer-
gence profile; the margins created by the ceramist are slightly
overcontoured due to the lack of tooth preparation.
The completed case fulfilled the treatment objectives to the
satisfaction of the patient; the final esthetic outcome was har-
monious and well balanced (Figs 11 to 17).

13
Fig 13 Pretreatment smile.
DISCUSSION
Tooth wear is one of the greatest challenges for clinicians and its
incidence is increasing, particularly in the young.12 It can be due to
several causes such as occlusal problems, parafunction, chemical
erosion, and habits;13 therefore the first step is correct diagnosis.
Tooth surface loss due to microbiologic activity results in
caries lesions. Erosion is the tooth surface loss through mineral
dissolution, as in the case of chemical agents or chelators act-
ing on plaque-free tooth surfaces (excluding bacterial plaque
acid).14 Erosion does not have any direct association with
mechanical or traumatic actions, although it often coexists
with attrition, abrasion, and abfraction. Attrition is the tooth
tissue loss caused by antagonistic tooth-to-tooth physical con-
tact. Abrasion is the physical wear as a result of mechanical pro-
cesses involving foreign abrasive substances; abfraction is the
physical wear as a result of tensile or sheer stress usually at the
cementoenamel region.15
The present patient showed signs of attrition, which is wear
from teeth rubbing against each other during mandibular move-
ments (Fig 1). Clinicians had several options to treat this prob-
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Imbelloni et al
14
Fig 14 Post-orthodontic treatment smile: the gingival mandibular
display has been corrected.
15
Fig 15 Harmony within the lips.
lem; however, nowadays the major requirement in every medical
field is to offer solutions that are both effective and conservative.
Among its numerous purposes, adult orthodontics allows a
reduction in the invasiveness of restorative therapy. The objec-
tives of the orthodontic therapy for this patient were: first, to
intrude the mandibular anterior incisors to make room in order
to restore them (to avoid traditional demolitive procedures that
in this case would have been crown lengthening, root canal
therapy, and crowns); second, to expand and align the maxil-
lary arch to obtain anteriorly more room for the mandibular
restorations and an even occlusal plane that would ease occlu-
sal function and the esthetic final outcome.
With the rapidly increasing demand for a beautiful smile
(which may improve the self-confidence of a patient), tech-
niques such as computer-aided imaging seem to enhance the
assessment of dental appearance. However, the present authors
prefer to deliver a mock-up to patients to wear over the teeth in
order to evaluate its design among friends and family members
who may influence the patient’s decision, until final approval of
the tooth arrangement is obtained. Consequently, a realistic
three-dimensional perception of the final result can be achieved.
301
 PROSTHODONTICS
16 17
In traditional prosthodontics, reconstruction of teeth is
based on crown preparation to create space for the prosthesis
and to ensure its durability over time, with consequent partial
sacrifice of healthy dental tissue not related to the pathologic
process that led to the need for treatment.
The ideal prosthesis, according to what has been defined as
“additive prosthodontics,” should not be subtractive but addi-
tive, so that the healthy dental tissues are not demolished and
only the lost tissues are replaced by adhesive techniques. Now-
adays, it is possible to realize restorations that are retained
without the need to prepare retentive walls.
The huge evolution of the field of adhesive dentistry allows
the reliable use of veneers16-21 that are much more conservative
compared to traditional prosthetic procedures: tooth prepara-
tion for ceramic veneers and resin-bonded prostheses removes
3% to 30% of the coronal tooth structure by weight, while that for
all-ceramic and metal-ceramic crowns removes 63% to 72%.22,23
The current tendency in conventional veneer procedures is
to use invasive tooth reduction similar to that of three-quarter
crown preparations, requiring local anesthesia, considerable
treatment time, and provisionals. To avoid these drawbacks, a
truly conservative approach to veneers with many substantial
advantages can be employed; the authors refer to it as “additive
veneers.” It is characterized in many cases by no preparation of
the teeth, in others by minor removal of enamel at selected
locations; either way, this procedure is highly simplified and
preserves natural tooth structure.
302 QUINTESSENCE INTERNATIONAL | volume 50 • number 4 • April 2019
Fig 16 Pretreatment photograph.
Fig 17 Posttreatment photograph:
at the end of the interdisciplinary dental
treatment the patient showed improved
self-confidence, with a dramatic
improvement to the look of his whole
face.
Adhesive cementation on enamel achieves the most stable
and long-lasting link between restoration and tooth structure.24-26
In a recent study, patients were treated with porcelain lam-
inate veneers and followed up to 12 years: it was concluded
that when these were cemented to enamel or to dentin surface
with enamel margins there were no cases of debonding, while
when cementation was on the dentin surface with dentin mar-
gins, debonding was very frequent (43%).27
Additive veneers can be made with thicknesses in the range of
0.3 mm to 0.5 mm, hence there is no need to cut down the facial
surface of the teeth to accommodate these restorations. This tech-
nique presents meaningful advantages: with no need to prepare
the teeth, there is no need for local anesthetic injections and no
need for provisional restorations. This greatly simplifies and expe-
dites the clinical procedure for the prosthodontist, achieving the
generally desirable goal of preserving natural tooth structure.
From the patient’s perspective, the absence of “shots and
drilling” makes the procedure more pleasant, and removes a
large barrier for individuals with phobias for dental treatment.
Furthermore, it is advantageous to avoid the psychologic reluc-
tance to having one’s teeth substantially cut down; it is very
comforting for the patient to know that their teeth remain
intact. Another benefit is the reduction in the incidence of pul-
pal sensitivity in conjunction with the preparation.
On the other hand, the major disadvantage is the necessity
to finish the marginal overcontours; when these are at the gin-
gival level the procedure often requires local anesthesia.
 Imbelloni et al

A light curing luting composite can be used for cementation
of porcelain veneers.28 A major advantage of light curing is that
it allows for a longer working time compared with dual curing:
it is then easier for the dental practitioner to remove composite
excess prior to curing, and the finishing time required is short-
ened. In addition, color stability is superior compared to that of
a dual-cured composite.
Nevertheless, it is important that light transmitted through-
out the ceramic veneer is sufficient to polymerize the light-curing
luting composite. Porcelain veneers absorb between 40% and
50% of the emitted light: the thickness of the porcelain veneer is
the primary factor determining the light transmittance available
for polymerization,29,30 while the color and the opacity of the por-
celain has less influence on the amount of absorbed light.31,32
Additive veneers are generally thinner than conventional
veneers. Hence, the former have better light transmission with
deeper polymerization that gives greater hardness to the luting
composite.
Post-cementation fractures are an occasional inconvenience
of these types of restoration, due to their thinness and brittle-
ness. The causes are: too much pressure or proximal contact
interference during the placement, overheating during finishing
and polishing if water spray is not used, and inadequate occlusal
adjustment. In the present patient, this problem did not occur.
Even if additional veneers are thinner than conventional
veneers, the margins of the first create (in some cases) overcon-
tours that must be finished and polished after bonding is com-
pleted, particularly at the gingival level to avoid periodontal
problems. Conventional wisdom holds that all adjusted porce-
lain surfaces should ideally be reglazed following chairside
adjustment and prior to cementation. However, research sug-
gests that this is not necessarily the case and that a polished
surface is comparable to a glazed surface, provided that an
appropriate polishing system designed specifically for the pur-
pose is used.33-36
The efficiency of porcelain polishing was found to be
improved when diamond instruments were used at moderate
speed with water spray, or when carbide instruments were
used at high speed without water spray.37
CONCLUSIONS
Tooth wear incidence is increasing, but dental professionals
often underestimate this problem so that in most cases it
slowly advances, causing severe problems.
In the present case report, a 40-year-old patient with the
chief complaint of worn mandibular incisors wished to improve
the esthetic appearance of his dischromic teeth with a noninva-
sive approach. First, a wax-up and a mock-up were created to
anticipate the final result. Second, a pre-prosthetic orthodontic
treatment allowed the generation of sufficient restorative space,
opening the bite anteriorly, to correct the space distribution of
the anterior maxillary teeth, and properly align the gingival mar-
gins of the maxillary anterior sextant. Finally, 20 additional
veneers were delivered to reconstruct the lost dental structure,
close the diastemas, and improve the color of the teeth.
While proper diagnosis and treatment planning as well as
precise execution of the treatment are important for the inter-
disciplinary approach, it is good communication and collabo-
ration among the specialists that is key to the success of the
final outcome.

REFERENCES
1. Reitan K. Clinical and histologic obser-
vations on tooth movement during and after
orthodontic treatment. Am J Orthod
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Arturo Imbelloni Arturo Imbelloni Specialist in Prosthodontics, Specialist in

Periodontology, Boston University, Boston, MA, USA; Private
Practice, Rome, Italy

Roberto Iafrate Oral Design Center, Fontana Liri, Italy

Cesare Luzi Specialist in Orthodontics, Aarhus University,

Aarhus, Denmark; Visiting Professor, University of Ferrara, Ferrara,
Italy; and Private Practice, Rome, Italy

Correspondence: Dr Arturo Imbelloni, Private Practice, viale G. Mazzini 55, 00195 Rome, Italy. Email: drarturo@studioimbelloni.com

304 QUINTESSENCE INTERNATIONAL | volume 50 • number 4 • April 2019