Restorative Dentistry

Enhanced CPD DO C

Luis Gustavo Barrote Albino

Eduardo Trota Chaves, Verônica Pereira de Lima and Giana da Silveira Lima

Restoration of Discoloured Incisors

with Ceramic Veneers:
A Workflow Case Report
Abstract: This case reports the treatment of two discoloured incisors with feldspar ceramic veneers using an integrated work approach,
and the active participation of a dental technician. The patient presented an upper left central incisor with a composite restoration, and a
lateral incisor with discolouration after trauma and endodontic treatment. Planning was developed in collaboration with the technician,
the decision was to perform ceramic veneers on the discoloured teeth. Central incisor previous restoration was included in preparation,
and lateral preparation was limited to create enough space for the veneer. This case highlights the importance of communication between
patient, clinician, and technician to achieve excellent results in restorative dentistry.
CPD/Clinical Relevance: Feldspar ceramic veneers might be a good option for masking light and mediumly discoloured substrates.
Dent Update 2024; 51: 22–27

Tooth discolouration is one of the most treatment should only include the adequate to resolve or minimize tooth
common outcomes associated with affected elements and not involve the discolouration.7–9 However, some cases
traumatic events.1 Colour changes can adjacent teeth with the aim of achieving require restorative treatments, such as
direct composite resin restorations.10
occur due to different causes, such chromatic harmony.4 The decision-
The masking ability of resin composites
as pulp necrosis or penetration of making process should consider the
is highly related to the technique and
endodontic cement into the dentinal patient’s expectations and demands
influenced by the thickness of the
tubules.2,3 In light of this, proposed regarding the restorative material and restoration and the use of opacifier
treatments should consider effective longevity of the treatment.5,6 agents and/or opaque resin composites.11
approaches to masking the darkened Conservative treatments, such as Additionally, the substrate-masking
substrate. Ideally, the proposed tooth bleaching techniques, can be process needs to be balanced against
compromising other aesthetic properties,
such as translucency.10,12 Furthermore,
the ageing of resin composites can result
Luis Gustavo Barrote Albino, DDS, Msc, PhD, Doctor, Graduate Program in Dentistry,
in long-term colour instability12 and
Federal University of Pelotas (UFPel), Pelotas, Brazil. Eduardo Trota Chaves, DDS, Msc,
require interventions such as polishing
PhD student, School of Dentistry, Federal University of Pelotas (UFPel), Pelotas, Brazil.
or refurbishment.13
Verônica Pereira de Lima, BDS, MSc, PhD, Lecturer, Academic Center for Dentistry
The aesthetics of the anterior
Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit, Amsterdam,
dental region may require particular
Netherlands; Guest Researcher, Radboud University Medical Center, Radboud Institute
thought. The dental optical properties
for Health Sciences, Department of Dentistry, Nijmegen, Netherlands. Giana da Silveira
of translucency and opalescence owing
Lima, DDS, MSc, PhD, Professor, Graduate Program in Dentistry, School of Dentistry,
to natural layering and the different
Federal University of Pelotas (UFPel), Pelotas, Brazil.
opacities within tooth structure) should
email: gianalima@gmail.com
also be considered.10,12 Dental materials

22 DentalUpdate January 2024

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a less dependent on the technical ability of
b actively participate in the treatment
c it is possible to fabricate restorations with
d involving the active participation of the
e better understanding of the process.
Figure 1. Initial presentation. (a) Lateral
excursion to the right side; (b) lateral excursion
to the left side; (c) maximum intercuspation;
and (d) protrusion. (e) Close-up view of anterior
maxillary teeth.
may not always be able to perform
these effects. Most restorative materials
reproduce dental effects in two main
forms either by adding pigments
(reproducing these proprieties in a static
configuration), or by trying to recreate
the same relation between light and
teeth, by producing tooth-similar optical
restorative materials. Also, as space is
required to apply these different layers,
the preparations can be more invasive,
resulting in a great loss of biological and
non-recoverable tissues.10–13
In contrast, ceramics have lower
discolouration potential when compared
to resin composites and might present
better colour stability over time.14–16
Additionally, as ceramic restorations are
manufactured in the laboratory, they are
January 2024
pg22-27 Trota.indd 23
the dental practitioner to obtain excellent
masking results. To achieve success, when
performing indirect restorations, good
communication between the dental
practitioner and technician is essential.17,18
Sometimes, the dental technicians can
planning, by being present at the dental
office, having a close examination of
the patient, and discussing technical
aspects of the treatment with the dental
practitioner.19,20 Although ceramic
restorations do require tooth preparation,
reduced thicknesses, thus minimizing the
extent of the required preparation.21
This case report presents the
treatment of two discoloured maxillary
incisors with feldspar ceramic veneers
using an integrated work approach,
technician in the treatment planning.
Case report
This report followed the principles
recommended by the CARE guidelines.22
CARE is a guideline that helps authors to
provide a complete case description, and
ensure that all the important details are
mentioned while making the reading of
case reports easier for the readers.
A 34-year-old male presented
for aesthetic treatment. During the
anamnesis, the patient reported a history
of trauma in the anterior maxillary area
related to a childhood bicycle accident.
The clinical examination revealed a
cervical discolouration in the central
and lateral maxillary right incisors (UL1
and UL2). Both teeth had undergone
endodontic treatment after the trauma.
The left central incisor had been fractured
by trauma and had been restored with
resin composite. The left lateral incisor
had not fractured, but was affected
by a discolouration process after the
endodontic treatment (Figure 1).
The patient reported previous multiple
attempts at tooth bleaching using different
techniques, but none could achieve the
desired results. The attempts at whitening
appeared to have been carried out in a
clinic using hydrogen peroxide gel, in
association with an at-home technique
with carbamide peroxide gel. The patient
did not know what concentrations of
either had been used.
The patient was also unsatisfied with
the resin composite restoration on the
Restorative Dentistry
right maxillary central incisor, which did
not mask the cervical discolouration.
Hence, considering that the tooth
had previously been prepared for the
direct resin composite restoration (i.e.
preparation for discolouration cases), the
patient and dental practitioner agreed on
an indirect restorative treatment with the
placement of feldspar ceramic veneers.
After preparation, the hypothesis that UL1
presented minor discolouration owing
to partial masking of resin composite
was confirmed. It was considered that
both teeth presented with the same
level of discolouration, justifying the
restorative planning.
For the integrated work approach,
the technician was invited to the dental
office during the initial appointments.
This way, the technician could better
understand the patient’s demands
and help in the treatment planning.
The association between dentist and
laboratory technician, in a consistent
line of communication, can provide
more desirable and reliable results. The
workflow philosophy is described for a
First, it is important to highlight that,
although the technician was present
in the clinical sessions, the patient’s
expectations and desires were considered.
As aesthetics is a subjective topic, when
this principle is not followed, there is
likely to be less patient satisfaction with
the final results.
After dental prophylaxis, an
impression using polyvinyl siloxane
(Silagum, DMG, Hamburg, Germany)
was taken to obtain models. The shade
of the teeth was recorded using a shade
guide (VITA classical, VITA Zahnfabrik, Bad
Säckingen, Germany). Using photographic
analysis, it was established that the
best match for colour selection would
be Vita shade B1 because the patient
had undergone previous bleaching
procedures. One concern was that
masking ceramics may not provide the
necessary translucency proprieties.
However, considering the shade map
studies for the specific case, it was
noticed that the cervical region was the
most affected. It is known that this area
does not present these optical effects, so
feldspar ceramic was the chosen option.
A silicone guide was obtained
from the model made before the tooth
preparation. Since this case did not
require alteration in dental form, the
DentalUpdate 23
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 Restorative Dentistry
a a
b
Figure 2. (a) Silicone preparation guide; (b)
colour evaluation with a shade guide; and (c)
lateral view of the dental preparations.
unprepared structure could guide
important aspects of the treatment,
such as dental preparation depth and
temporary restoration placement.
The operative field was isolated with
a rubber dam and dental preparation
was performed with 12-fluted tungsten
carbide burs (H375R, Cosmedent,
Chicago, Il, USA). The preparation
consisted of removing the existing
restoration on the central incisor, limited
to the supragingival level, to create
the necessary space for the veneer
(Figure 2).
24 DentalUpdate
pg22-27 Trota.indd 24
a
b
Figure 3. (a) View after preparation in maximum
intercuspation; (b) close-up view of the prepared
teeth; (c) close-up view of the anterior maxillary
teeth; and (d) view in protrusion.
Both restored teeth presented with
previous restorative material (resin
composite), with the central incisor
having a large restoration involving both
labial and incisal surfaces, which could
explain the discolouration perception
in this tooth. The restorative plan was
to remove 0.8 mm of the restoration
labially, and 1.0 mm incisally.
The lateral incisor presented with
a minor mesial restoration. Thus,
planning for this tooth aimed to achieve
the necessary space for an adequate
adaptation to a thin laminate ceramic
veneer as well as complete masking of
the background. The restorative plan was
to remove 0.6 mm of the tooth labially,
and 0.8 mm incisally. After preparations,
a new impression was performed, and
the models and photographs were sent
to the dental technician (Figure 3).
Figure 4. (a,b) Trial of the veneers;
(c,d) occlusion check with the veneers in place
before cementation.
In this intregrative workflow
approach, the dental technician
manufactured the feldspar veneers
in a reduced time compared to
the conventional protocol, and the
provisionals remained in place for
less than 1 week. This process avoids
the need for replacing the temporary
restorations, which is a common
procedure for ‘long-term’ bisacryl
restorations. Additionally, reducing the
length of time temporary restorations
are in place also avoids inflammation of
gingival tissues.
Regarding the chosen material and
patient request (that once underwent
a previous restorative procedure with
direct resin composite), it was defined
that an indirect procedure could
produce better results, considering
clinical time and the possibility to
stay in a less-invasive field. Feldspar
ceramics was elected as the best option,
from a range of possibilities. Despite
the clinical and technical experience
of the operators, the material can
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a a
b
d c
d c
e
Figure 5. (a) Application of 37% phosphoric
acid; (b) after removal; (c) application of adhesive
system; (d) view after cementation; and (e) close-
up view after removal of the rubber dam.
provide adequate results for non-severe
discolouration cases.
The feldspar ceramic veneers were
placed on the substrate using a try-
in paste with the same colour as the
intended cement (NX3, Kerr Corp A2) to
confirm its masking ability and overall
colour match (Figure 4). After the patient’s
approval, the dental substrate was
conditioned with 37% phosphoric acid
(Power Etching; BM4, Palhoça, SC, Brazil),
and two layers of the adhesive system
(Adper Single Bond 2; 3M ESPE, St Paul,
MN, USA). The ceramic veneers were
etched with 10% hydrofluoric acid (Power
etching 10%; BM4) for 120 seconds. A
silane coupling agent (Silane Primer; Kerr
Corp, Orange, CA, USA) was applied for
60 seconds and air-dried (Figure 5).
January 2024
pg22-27 Trota.indd 25
Restorative Dentistry
Figure 7. High contrast photograph, highlighting
the adequate masking of the veneers.
a
d
Figure 6. (a,c) Pre- and (b,d) post-
restorative views.
The veneers were bonded to the
prepared teeth using a light-cured
resin-based cement, shade A2 (NX3; Kerr
Figure 8. At the 3-month follow-up: (a) lateral
Corp). After removing the excesses, a
excursion to the right side; (b) protrusion;
photocuring unit (Demi; Kerr Corp) was (c) lateral excursion to the left side; and
used. A layer of glycerine gel was applied (d) maximum intercuspation
before the final photoactivation. The
rubber dam was removed, remaining
cement was removed with a #12 blade,
and the contacts were checked and patient had no biofilm retention areas or
adjusted (Figure 6). dentine hypersensitivity (Figure 7).
A slight open margin can be The patient was satisfied with
identified in UL2 owing to the the final result of the restorations,
cementation process and veneer margin
considering that the superior lip could
adaptation. Despite this undesirable
event, the clinicians and patient agreed hide the high cervical surface. In
to carry out monitoring and intervene 3-month follow up no alterations were
only if necessary. This management identified (Figure 8). The case continues
was considered acceptable because the to be monitored.
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 Restorative Dentistry
Discussion
In this case report, the treatment of
two discoloured maxillary incisors with
feldspar ceramic veneers was performed
with an integrative workflow approach
in collaboration with the dental
technician. The high aesthetic demand
of the patient and the decision to
intervene for only the two discoloured
teeth increased the complexity of the
case. However, the technician’s presence
during the appointments favoured
communication and facilitated the
manufacturing of the veneers once
the technician could see in person the
critical areas for masking the substrate
and had a better overview of the case.
Cases that require only colour
changes have the advantage of allowing
the patient’s initial model to be used
as a guide for temporary restorations,
eliminating the need for diagnostic wax-
up.23,24 From an initial impression, before
dental preparations, it was possible
to obtain a model that presented the
exact dimensions in size and volume as
the original teeth. This model allowed
the creation of a silicone guide, which
can be used as a tray for applying
bisacryl resin and as a guide for teeth
preparation, thus, aiding essential steps
of restorative treatment.23,24
Tooth discolouration should
preferably be treated with conservative
approaches, such as tooth bleaching
techniques.3,25 The decision-making
process should take into account the
patient’s history and demands.26,27 In the
present case, the patient had previously
undergone different tooth bleaching
techniques without reaching the desired
outcome. However, the previous tooth
bleaching may have contributed to
reducing the initial discolouration
within the biological limits for the
patient,7,26,27 making it possible, in this
case, to reduce the preparation to the
minimum necessary for masking with
indirect veneers.7
Internal bleaching could have been
a possibility for reducing discolouration
and allowing less invasive preparations.
However, the clinician and patient
agreed that it would be best not to
interfere with the well-performed
endodontic treatment. Internal
bleaching requires access through the
palatal surface, and this procedure
could remove healthy dental structure.
It was considered that performing the
26 DentalUpdate
pg22-27 Trota.indd 26
preparation over the resin composite,
on both the labial and incisal surfaces,
would reduce dental wear and be the
least invasive course of action.
Resin composite can be valuable for
masking discolourations.10 In general,
this material does not require dental
preparation and has good adhesion
properties. However, for certain types
of discolouration, preparation may
be necessary to allow an adequate
thickness of the restorative material
to mask it fully.10,12,27 Since the patient
already had a direct resin composite
restoration on his maxillary right central
incisor, and the discolouration was still
noticeable, this indicated the need for
an extra thickness of the restorative
material. This indication and the
aesthetic demand of the patient were
considered for the decision of adopting
ceramic veneer as the chosen approach.
Ceramic restorations can be made
with different materials and in different
thicknesses. While, in the past, ceramic
veneers had to be had to be formed
in many layers, necessitating heavy
tooth preparation, it is now possible to
produce thin veneers, called laminates.
Laminates have been studied over
the past decades with favourable
results. Interventions with laminates
show a high rate of survival and do
not jeopardize the tooth’s lifespan
and/or function.28 Considering the
development of dental science and
materials, it is possible to perform long-
term ceramic restorations. Individual
patient characteristics, such as age
and habits, can directly influence the
restoration lifetime, but in general,
adequate results can be achieved, once
material characteristics and biological
principles are respected.28
Given a conservative strategy, the
decision was made to intervene only
on the two discoloured teeth in the
present case, increasing the challenge
of masking the discoloured substrate
while mimicking the characteristics
of the adjacent teeth.27,30 Our report
emphasizes the possibility of achieving
excellent results without involving
adjacent teeth based on an integrated
work approach.19,20
Body image and self-perception
represent important aspects of human
beings. Although it is common sense
that the perfect body, face, or teeth
are not possible achievements, human
beings keep looking for different
approaches, to improve their physical
characteristics.31 Slight changes and
alterations can produce good benefits
psychologically; however, when it
becomes an obsession, a dysmorphic
condition may be present. In the present
case, the patient presented with a
high aesthetic demand and concerns
about his teeth, which could configure
an important warning for dentists in
anamnesis and clinical examinations.
Dysmorphia is not an easy condition to
identify, although it is quite common at
present. Dental literature is still scarce,
although it is an important field for
further research.31
As a limitation, it is possible to
address that this is one case of good
results for masking discoloured teeth
with feldspar ceramics in an integrated
workflow, so it would be interesting for
other practitioners to describe similar
cases and help to enrich the literature. It
is also possible to address as a limitation
the slight cervical margin on UL2,
considering that this weakness could
lead the treatment to be less satisfactory.
Overall, patient satisfaction is the
strongest point for using this integrated
workflow approach and it might be a
good alternative for similar cases.
Conclusion
Masking discoloured teeth can
be a challenge for clinicians. This
case highlights the importance of
communication between the patient,
clinician and technician to achieve
excellent results. After more conservative
options have been explored, restorative
options can be used to meet a patient’s
aesthetic demands. Feldspar ceramic
veneers may be a good option for
masking discoloured substrates because
they can be manufactured with a small
thickness, which avoids extensive dental
preparations. The patient was satisfied
with the final result.
Acknowledgements
The authors thank ceramist Francisco
Mello, member of the Oral Design
International Foundation, and Osmar
Gradinar, DDS, for technical assistance.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
January 2024
11/01/2024 12:12

Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
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