Etched porcelain veneer restoration of a primary tooth: A clinical report
Galiatsatos A. Aristidis, DDS, Dr Denta
University of Athens, Athens, Greece
Hypodontia is a congenital absence of 1 or more
permanent teeth, and has been observed in 3.5% to
9.6% of the population, in which the absence of third
molars is not included. Hypodontia is seen mostly
in the permanent dentition and it may be unilateral
or bilateral. Genetic factors, environmental factors,
endocrine disturbances, or viral diseases such as rubella
or scarlet fever, and nutritional deficiencies (vitamin B)
during pregnancy, may be causal factors.1-5
For missing permanent teeth, the primary tooth may
be retained and need restoration. For esthetic and func-
tional reasons, this may cause clinical problems, espe-
cially in the anterior region. Clinically, there are impor-
tant differences between the primary and permanent
teeth,6 such as the primary tooth has a shorter crown;
the occlusal table is proportionally narrower; the enam-
el and dentin layers are thinner in the primary tooth;
the pulp is larger in relation to the crown size; the pulp
horns are closer to the outer surface of the tooth; the
form of the pulp chamber follows the surface of the
crown, usually with a pulp horn under each cusp; and
the roots of the posterior teeth are longer and more
slender in comparison with crown size of a permanent
tooth. Treatment options may include extraction of the
primary tooth and possible orthodontic movement of
the remaining dentition, extraction of the primary
tooth and placement of a fixed or removable prosthe-
sis, and full crown coverage and/or restoration of pri-
mary tooth contour to mimic a permanent tooth with
esthetic restorative materials.7,8
Composites are used frequently as veneering materi-
als. With experience and the use of multiple layering
techniques, excellent esthetic results may be achieved.
However, if the composite is not handled correctly, the
following problems could be observed: (1) low resis-
tance to the surface abrasion of tooth brushing and
abrasive foods,9 (2) loss of surface luster,10 (3) loss of
color and surface staining,10 (4) biologic incompatibil-
ity with gingival tissues,11 or (5) cohesive fracture.12
A laminate veneer with a labial surface of porcelain
could improve the many shortcomings of the compos-
ite veneer. Glazed porcelain is nonporous, resists the
accumulation of debris, and is tolerated better by the
soft tissues than any other dental material.12 Glazed
Presented at the 18th Hellenic Dental Congress, Hellenic Dental
Association, Thessaloniki, Greece, October 1998.
aInstructor, Department of Fixed Prosthodontics.
J Prosthet Dent 2000;83:504-7.
504 THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Retained maxillary primary canine with mesial and
distal diastemata.
porcelain may be colored, tinted, and characterized to
an excellent esthetic result. Also, superior veneer
strength and retention are possible with etched porce-
lain veneer. Thus, etched porcelain veneers appear to be
more prudent restorative alternative in situations
requiring lengthening of teeth or involving functional
occlusal contacts.13-17
The purpose of this clinical report is to describe an
esthetic restoration of a retained primary canine in an
adult dentition by means of an etched porcelain veneer.
CLINICAL REPORT
A 21-year-old female patient who had hypodontia
and underwent orthodontic treatment had a retained
primary maxillary canine (Fig. 1). The tooth was not
mobile and a radiograph revealed no permanent suc-
cessor. After discussion of possible treatment modalities
with the patient, the decision was made to restore this
tooth with an etched porcelain veneer.
Tooth preparation was carried out using a fine dia-
mond stone in a high-speed handpiece with copious
water coolant. Because the enamel was not penetrated,
local anesthetic was not required. A light finishing
chamfer was used gingivally (Fig. 2), which allows for a
sufficient thickness of porcelain, with little or no over-
contouring of the porcelain veneer. The preparation
was carried to the lingual aspect of the tooth (Fig. 3) to
allow for an increase of the incisal length and for suffi-
cient bulk of porcelain. Enamel modification, an
important consideration, must be accomplished slowly
and its reduction should never exceed its thickness.
An elastomeric impression of the prepared tooth was
made after the retraction cord was removed. Because
VOLUME 83 NUMBER 5
ARISTIDIS THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 2. Primary tooth after preparation.

the preparation was restricted to the enamel, it was not

Fig. 3. Extension of preparation onto lingual aspect of tooth.
noticeably objectionable to the patient, and no tempo-
rization was required. A working cast with a removable
die of the prepared tooth was fabricated and forwarded
to the laboratory. Specific instructions for the laborato-
ry were given in the work authorization regarding the
shape and color, incisal translucency, and characteriza-
tions for masking out intrinsic tooth stains.
The veneer was returned with the labial surface
glazed. The marginal fit was verified on the master cast
and the veneer was inspected for fracture lines, chips, or
other defects that may preclude successful placement.
The veneer was placed intraorally, and the fit was excel-
lent. Occlusion was checked to ensure that the veneer
fit without changing the group function present on the
premolars, which was present preoperatively on the
natural dentition. In addition, the color was verified as Fig. 4. Acid-etched intraenamel preparation exhibits lightly
excellent without need for color modification by the frosted appearance.
composite luting agent. The veneer was returned to the
laboratory for etching of the fitting surface.
At the third appointment, the veneer was returned Excess composite was removed with a fine-grit flame
from the laboratory with the fitting surface etched with diamond, while adequate protection of the gingival tis-
hydrofluoric acid. A silane coupling agent (Monobond sues was maintained at all times. Palatal and labial sur-
S, Vivadent, Schaan, Liechtenstein) was placed on the faces were finished with silicon porcelain finishing
inner surface and allowed to dry for 1 minute. The points and interproximal finishing was carried out with
tooth was isolated using a celluloid strip and etched aluminum oxide strips. Finally, the occlusion was exam-
with 37% phosphoric acid gel for 1 minute. This was ined in centric and eccentric movements using ultrathin
followed by a 30-second water bath and air drying. articulating paper to ensure that no functional interfer-
This etching procedure was repeated in the same order ences had been introduced. Figures 5 and 6 illustrate
because the primary enamel surface is different from the veneer immediately after cementation.
the permanent enamel surface.17 At the end of etching
DISCUSSION
procedure, the tooth was air-dried to create a frosted,
chalky appearance. (Fig. 4). Bonding of facial veneers has been performed for
A small amount of a selected shade of dual-polymer- more than 10 years and has become a useful and rec-
izing composite cement (Variolink II, Vivadent) was ognized technique.18-20 Clinical studies21-23 have
applied to the internal surface of the veneer. The veneer reported the excellent performance of such restorations
was gently vibrated into place using finger pressure. in terms of fracture rates, microleakage, debonding,
The correct adaptation of the veneer both labially and and periodontal response. Advantages of porcelain lam-
lingually was verified before the composite was light inates are numerous and result from the combined
cured for 60 seconds. advantages of composite (adhesion, economy of tooth

MAY 2000 505

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 5. Veneer immediately after insertion.
substrate) and ceramics (color stability, wear resistance,
enamel-like thermal expansion, and refined esthetics).
For missing permanent teeth, the primary tooth
requires restoration, and in this clinical report, a prima-
ry canine was recontoured both incisally and interprox-
imally; thus, there was an increase in buccolingual
thickness and incisal length and also an improvement in
esthetics. The use of an etched porcelain veneer has
many advantages. Compared with a full crown, a porce-
lain veneer is a conservative alternative because minimal
tooth preparation is necessary. Compared with com-
posite laminate, porcelain is more stable in the oral
environment. Superior veneer strength and retention
are possible with etched porcelain veneers.15,16,24,25
For this reason, etched porcelain veneers appear to be a
more prudent restorative alternative in situations that
require significant lengthening of teeth.
Contraindications of this procedure include teeth in
severe labial position, exposed dentin, poor oral
hygiene, a mobile primary tooth, and existence of per-
manent successor (radiographically). A major consider-
ation is the occlusion. Unilateral balanced occlusion,
also known as group function of the teeth on the work-
ing side during a lateral excursion, distributes the
occlusal load.26 Therefore, adequate room for increas-
ing incisal length of a primary canine without changing
the group function that is usually evident on the per-
manent premolars should be verified on the diagnostic
wax-up.
The procedure used in this clinical report differs
from traditional techniques. The preparation was
extended to the lingual surface of the tooth to allow for
an increase of the incisal length and for sufficient bulk
of porcelain. The etching procedure was performed
twice by applying a 30% phosphoric acid etchant gel to
the prepared tooth, which was allowed to set for 1
minute, after which the tooth was rinsed with a steady
stream of water for 30 seconds. Investigators have
examined the retentive qualities of acid-etched primary
tooth enamel and have observed that conventional
etching procedures produce primary enamel surfaces,
which were less retentive than similarly etched perma-
nent enamel surfaces.27-29
506
ARISTIDIS
Fig. 6. Occlusal view of prosthesis after cementation.
The different etching pattern observed in primary
enamel is explained by the existence of a prismless enam-
el layer that covers the outer enamel surface.27,28 From
a clinical standpoint, several approaches have been taken
in an attempt to improve the etching characteristics of
primary enamel and to increase the retention of resins
applied to these surfaces. The most widely advocated
approaches have been the mechanical removal of the
outer layer of enamel before etching and the use of pro-
longed exposure times to etching agents.27,29-33
SUMMARY
The treatment of a retained primary tooth in the
adult dentition has always been a difficult clinical prob-
lem. In the anterior region of the mouth, the problem
is further complicated by esthetic requirements. In this
clinical report, a primary canine was recontoured both
incisally and interproximally with an etched porcelain
veneer to provide an esthetic result. The use of etched
porcelain as an indirect veneer material, which has
demonstrated clinical success, is an alternative to the
requirements of conservative dentistry, namely, preser-
vation of tooth substance and safeguarding primary
tooth vitality.
The procedure used in this clinical report differs
from traditional procedures. The preparation was
extended to the lingual surface of the tooth, which
allowed for an increase of the incisal length and added
a sufficient amount of porcelain. The etching proce-
dure was performed twice by applying 30% phosphoric
acid etchant gel to the prepared tooth.
VOLUME 83 NUMBER 5
ARISTIDIS
REFERENCES
1. Eronat N,Ertugrul F. An unusual case of hypodontia with extensive caries:
a multidisciplinary treatment approach. J Clin Pediatr Dent 1991;15:199-
201.
2. Brook AH. A unifying aetiological explanation for anomalies of human
tooth number and size. Arch Oral Biol 1984;29:373-8.
3. Graber LW. Congenital absence of teeth: a review emphasis on inheri-
tance patterns. J Am Dent Assoc 1978;96:266-75.
4. Meskin LH, Gorlin K. Agenesis and peg-shaped, permanent maxillary lat-
eral incisors. J Dent Res 1963;42:1476-9.
5. Hobkirk JA, Brook AH. The management of patients with severe hypodon-
tia. J Oral Rehabil 1980:7:289-98.
6. Mathewson RJ, Primosch RE, Robertson D. Fundamentals of pediatric
dentistry. 2nd ed. Chicago: Quintessence Publishing Co; 1987. p. 215-24.
7. Croll TF. Primary canine full coronal restoration: new considerations.
Quintessence Int 1985:16:143-7.
8. Tripodakis AP. Congenital partial anodontia: prosthodontic considera-
tions. Int J Prosthodont 1988:1:175-80.
9. Horn HR. Porcelain laminate veneers bonded to etched enamel. Dent
Clin North Am 1983:27:671-82.
10. Black JB. Esthetic restoration of tetracycline-stained teeth. J Am Dent
Assoc 1982;104:846-50.
11. Boyer DB, Chalkley Y. Bonding between acrylic laminates and composite
resin. J Dent Res 1982;61:489-92.
12. Craig RG, Peyton FA. Restorative dental materials. 8th ed. St Louis: CV
Mosby; 1989. p. 170-84, 255-86.
13. Simonsen RJ, Calamia JR. Tensile bond strength of etched porcelain. J
Dent Res 1983;62(Spec Issue):297.
14. Boksman L, Jordan RE, Suzuki M, Galil KA, Burgoyne AR. Etched porce-
lain labial veneers. Ont Dent 1985;62:11-9.
15. Calamia JR. Etched porcelain veneers: the current state of the art. Quin-
tessence Int 1985;16:5-12.
16. Calamia JR, Simonsen RJ. Effect of coupling agents on bond strength of
etched porcelain [abstract]. J Dent Res 1984;63:179.
17. Smutka S, Jedrychowski J, Caputo AA. An evaluation of primary enamel
pretreatments and their effects on resin retention. J Dent Res 1978;57:
796-9.
18. Sheets CG. Advantages and limitations in the use of porcelain veneer
restorations. J Prosthet Dent 1990;64:406-11.
19. Freidman MJ. Augmenting restorative dentistry with porcelain veneers. J
Am Dent Assoc 1991;122:29-34.
20. Freidman MJ. Current, state-of-the art porcelain veneers. Curr Opin Cos-
met Dent 1993:28-33.
MAY 2000
THE JOURNAL OF PROSTHETIC DENTISTRY
21. Calamia JR. Clinical evaluation of etched porcelain veneers. Am J Dent
1989;2:9-15.
22. Calamia JR. The current status of etched porcelain veneer restorations. J
Indiana Dent Assoc 1993;72:10-5.
23. Rucker LM, Richter W, Macentee M, Richardson A. Porcelain and resin
veneers clinically evaluated: 2-year results. J Am Dent Assoc 1990;121:
594-6.
24. Boyer DB, Chalkley Y. Bonding between acrylic laminates and composite
resin. J Dent Res 1982;61:489-92.
25. Wall JG, Reisbick MH, Johnston WM. Incisal edge strength of porcelain
laminate veneers restoring mandibular incisors. Int J Prosthodont
1992:5:441-6.
26. Shillingburg HT Jr, Hobo S, Whitsett L, Jacobi R, Brackett S. Fundamen-
tals of fixed prosthodontics. 3rd ed. Chicago: Quintessence Publishing;
1997. p. 19.
27. Sheykholeslam Z, Buonocore MG. Bonding of resins to phosphoric acid-
etched enamel surfaces of permanent and deciduous teeth. J Dent Res
1972;51:1572-6.
28. Gwinett AJ. Human prismless enamel and its influence on sealant pene-
tration. Arch Oral Biol 1973;18:441-4.
29. Eidelman E. The structure of the enamel in primary teeth: practical appli-
cations in restorative techniques. ASDC J Dent Child 1976:43:172-6.
30. Conniff JN, Hamby GR. Preparation of primary tooth enamel for acid con-
ditioning. ASDC J Dent Child 1976;43:177-9.
31. Christensen GJ. Acid etching of teeth—current status. J Pedod 1977;1:
187-97.
32. Schneider PM, Messer LB, Douglas WH. The effect of enamel surface
reduction in vitro on the bonding or composite resin to permanent human
enamel. J Dent Res 1931;60:895-900.
33. Fuks A, Eidelman E, Shapira J. Mechanical and acid treatment of the
prismless layer of primary teeth vs acid etching only. A SEM study. J Dent
Child 1977;54:222-5.
Reprint requests to:
DR GALIATSATOS A. ARISTIDIS
60 STR ROGAKOU ST
15125 ATHENS
GREECE
FAX: (30)685-2823
Copyright © 2000 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2000/$12.00 + 0. 10/1/106501
doi:10.1067/mpr.2000.106501
507