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AbstractThis article presents an esthetic rehabilitation with “contact lens” porce-lain veneers in a young woman with an unesthetic smile due to significant tooth darkening, vestibularization of upper canines, diastemas, and discrete lingualization of the upper central and lateral incisors. The rehabilitation consisted of in-office and at-home bleaching, followed by the placement of ultra-fine veneers. It can be concluded that previous dental whitening can be considered a conservative treatment since “contact lens” porcelain veneers can be carried out with minimal or no preparation in naturally darkened teeth. The results show a harmonious smile with minimal biological costs.

Key Words: ceramics, bleaching, esthetics, minimally invasive dentistry, minimal and no-preparation restorations, veneers

A Harmonious Smile with Minimal Biological CostsThe Importance of Light Substrates for “Contact Lens” Porcelain Veneers

Rafael Almeida Decurcio, DDS Paula de Carvalho Cardoso, DDSAna Paula Rodrigues de Magalhães, DDSEduardo Mederiro

CLINICAL COVER CASE

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Decurcio/Cardoso/de Magalhães/Mederiros

The evolution of restorative materials and adhesive systems…has led to a new era in dentistry in which full-ceramic restorations are performed with esthetic, functional, and long-lasting results.

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IntroductionThe evolution of restorative materials and ad-hesive systems, in conjunction with society’s ever-increasing desire for esthetic outcomes, has led to a new era in dentistry in which full-ceramic restorations are performed with esthetic, functional, and long-lasting results.1,2 These improvements allow for the application of modern restorative principles, including maximum preservation, maximum preven-tion, and minimal wear.3,4

This new philosophy of “prevention of extension” aims to minimize the biological costs to the natural tooth,5 leading to a change in traditional preparations and the creation of a new classification for no-preparation porce-lain veneers: “contact lens” porcelain veneers. These are defined as ultra-fine (0.1 to 0.7 mm thick) ceramic laminates strongly bonded to tooth enamel with minimal or no tooth wear.6,7

In this technique the ceramic shapes are guided by a tooth’s pre-existing defects, such as shape and incisal edge flaws, fractured or conoid teeth, small diastemas with parallel walls, re-establishment of anterior and/or ca-nine guides, and increase in occlusal vertical dimension. In these situations, the substrate for cementation is tooth enamel, which is ex-tremely favorable for adhesion.8

Adhesion to enamel remains the most re-liable mechanism for dental adhesion. The acid etching selectively dissolves the enamel prisms, creating microporosities that are in-filtrated by bonding agents—even the hydro-phobic ones—through capillary action. After photocuring, small monomer extensions are formed among the prisms and create the best adhesion possible to the tooth substrate. This not only effectively seals the restoration mar-gins but also protects the vulnerable dentin adhesion from degradation.9-11

“Contact lens” porcelain veneers should be utilized only on lighter teeth, as the substrate shade has a great influence on ultra-fine por-celain laminates.12 That requirement is part of the porcelain veneers rehabilitation protocol due to the need to harmonize all substrate shades involved. Furthermore, it is a conser-vative treatment in which minimal wear of naturally darkened teeth is enough to obtain a higher value in color with the ceramics luted to the substrate, and also maintain a higher enamel volume.

Patient Complaint, Diagnosis, and Treatment PlanAn 18-year-old female was dissatisfied with her smile due to significant tooth darkening, vestibularization of the upper canines, diastemas, and discrete lingualization of the upper central and lateral incisors.

Orthodontics was presented as the first treatment option, to align the teeth in the arches before the rehabilitation. However, the patient did not accept this, stating that her job would not allow her to have braces on the vestibular or lingual faces of her teeth.

According to Medeiros,13 a basic photography protocol for registration of the patient’s initial and final conditions must include high-quality images of the patient’s entire face, not just the smile. There must also be standard-ization of the framework and equipment configurations to facilitate future comparisons of the initial and final conditions. This photography protocol played a major role in obtaining the digital facebow composed by the refer-encial lines: vertical midline, and vertical nasal alar line (Figs 1a & 1b). The digital facebow is a standardized method for analysis of facial, dentolabial, and esthetic references.

Figure 1b shows that the vertical nasal alar line on the right side follows the distal part of the upper canine, considered an ideal esthetic condition. However, the left nasal alar line follows the medium third of the buccal face of the first upper premolar, different from the esthetic standard and from the right side. When this line coincides with the distal face of the upper canines it is characterized as an ideal width for the six anterior upper teeth during smiling. This case could have been solved with orthodontics and, later on, rehabilitation, but as previously mentioned, the patient rejected this option.

The smile photography protocol also played a major role obtaining the horizontal incisal edge line (Figs 2a & 2b). Figure 2b shows that there is no parallelism between the imaginary line that follows the incisal edge of the upper anterior teeth and the line that follows the border of the lower lip. This indictes a need to increase the length of the central and lateral incisors.

To complement the treatment planning, smile and intraoral photographs were taken with shade tabs (Figs 3 & 4), making the physiological darkening (shade A3, Vita Classical, VITA Zahnfabrik; Bad Säckingen, Germany) even more noticeable.

Intraoral photographs (Figs 5-7) confirmed the vestibularization of the upper canines, diastemas, and lingualization of the central and lateral inci-sors.

Due to the patient’s age and according to modern restorative principles, the treatment plan was established based upon maximum preservation, maximum prevention, and minimal wear.

“Contact lens” porcelain veneers should be utilized only on lighter teeth, as the substrate shade has a great influence on ultra-fine porcelain laminates.

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Figure 3: Smile photograph with color tabs positioned for initial color evaluation; this image helps the patient and dentist to observe tooth colors in relation to the lips.

Figure 4: Intraoral photograph with color tabs positioned for initial color evaluation; this image allows observation of tooth colors only.

Figure 1: Initial photographs of the patient: a) without the referential lines, b) with the lines that form the digital facebow.

a b

Figure 2: a) initial smile, b) lines showing the absence of paralelism between the incisal edge of the upper anterior teeth and the lower lip.

a b

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Figure 5: Intraoral photograph with dark contrast reveals details of the patient’s tooth color and anatomy.

Figure 6: Intraoral image of the patient’s teeth in occlusion; diastemas and vestibularization of canines can be evaluated.

Figure 7: Intraoral occlusal image confirming the vestibularization of canines and lingualization of the central and lateral incisors.

TreatmentThe first step was in-office and at-home bleach-ing. Six daily 45-minute applications of carb-amide peroxide 37% (PowerBleaching, BM4; Santa Caterina, Brazil) without a barrier layer were carried out in the office. Two-hour at-home applications of carbamide peroxide 10% or 16% (PowerBleaching) were done daily for 20 days. By the end of the whitening period (Figs 8a-8c), a significant color change—from A3 to 1.5M2—was observed (Fig 9).

During the initial smile analysis, it was oberved that the left nasal alar line did not co-incide with the distal face of the correspond-ing canine, suggesting a need for intervention. However, considering the patient’s age, as well as the anatomic details observed in the canines and their vestibular position, deep preparation (with probable dentin exposure) was needed to achieve the best results. It therefore was decided not to intervene in the canines, thus preserving their integrity and using them as the parameter for volume gain of the other teeth, even if this decision would result in certain limitations of the esthetic result when compared to ideal es-thetic references.

It was important to make a dental waxing from the ideal dimensions established from the facial reference chosen, the interpupillary distance (Fig 10).14 With the interpupillary distance value divided by 6.6, the ideal width of the maxillary central incisors was obtained. The width of the upper lateral incisors was 75% smaller than the central incisors. From the widths the lengths were calculated, with the central incisor following a relationship of 100 x 80 (length x width), and the lateral incisor be-ing 1.0 to 2.0 mm smaller than the first one.8 Then, a mock-up was done to evaluate the prob-able result (Figs 11 and 12a – 12c). The mock-

up was made from silicone putty (Zetalabor, Zhermack; Badia Polesine [RO], Italy) obtained from the waxed cast, filled with bis-acrylic resin (Protemp 4, 3M ESPE; St. Paul, MN), and kept in position in the patient’s mouth for five minutes. Observation of the mock-up confirmed that the planned treatment would pro-duce a good esthetic result, with preservation of the canines due to the bleaching done previously.

Phonetic tests were performed, and the patient was able to pronounce “F,” “S,” and “V” with no disturbances. In addition, an evaluation of the exposure of the maxillary central incisors with the lips at rest showed an appropriate amount of visible teeth (approximately 3.4 mm for females), confirming the treatment planned on the waxing.8 When minimal or no preparation is done there is a risk of ending up with bulky teeth; this can be evaluated in the mock-up. However, in this case the patient had no complaints about it as the four anterior maxillary teeth were actually lingualized, requiring more volume.

After the patient approved the mock-up, the next step was to take impressions. After selecting the trays and application of the adhesive for addition silicone (Universal Tray Adhesive, Zhermack), heavy-body Elite HD (Zhermack) was po-sitioned on the tray and over it a thin leaf of polyvinyl chloride. This leaf is used to create a distance between the teeth and the heavy putty, keeping enough space for relining with the regular putty. Then, knitted cords of the thinnest diameter (Ultrapack 000, Ultradent Products; South Jordan, UT) were inserted in the gin-gival sulcus, one for each tooth. A thicker knitted cord was then inserted in one piece, from the distal face of the first tooth in one side to the distal face of the last one in the other, skirting and preserving the integrity of the surrounding gingival tissue. After 10 minutes with the cords in position promoting mechanic separation of the gingival tissue, the second cord was removed and the regular putty of the addition silicone was applied in the sulcus region, over the first cord, in all extensions of the cervical margin, and on the heavy putty impression, The tray was then brought to the right position in the mouth to wait for the correct setting time.

Observation of the mock-up confirmed that the planned treatment would produce a good esthetic result with preservation of the canines due to the bleaching done previously.

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Figure 8: Smile photographs showing the result of the whitening technique, with significant color change obtained for all teeth: a) frontal, b) right, c) left.

a b c

Figure 9: Photograph with the color tab showing the new color obtained with bleaching (1.5M2).

Figure 10: Dental waxing obtained from the ideal dimensions established from the facial reference chosen, the interpupillary distance. The canines were not included in the waxing.

Figure 11: Facial image with the indirect mock-up showing the good esthetic result that could be obtained with the treatment plan proposed.

Figure 12: Close-ups of the mock-up showing a harmonious disposition of the teeth: a) right side smile, b) frontal smile, c) left side smile.

c

b

a

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Along with the photographs obtained to guide the laboratory technician through the clinical condi-tions presented and chromatic characterizations of the teeth, the casts and occlusal registration were sent to the laboratory for the development of the ceramic ve-neers. Because there was no preparation, there was no need for provisional restorations. Figure 13 shows the “contact lens” porcelain veneers made with lithium disilicate ceramic (e.Max, Ivoclar Vivadent; Schaan, Liechtenstein) with the pressed technique and then painted to look more natural.

After the substrate was cleaned with brushes, pum-ice stone, and water, the veneer was positioned with no material under it straight in the tooth surface to evaluate the adaptation. As no interference or mis-matching was identified between ceramics and teeth, the color trial was done with try-in paste (Variolink Veneer Medium, Ivoclar Vivadent) (Fig 14). The pa-tient was asked to look in a mirror and approve the trial of the veneers before cementation to ensure that the color and shape were satisfactory.

The inner ceramic surface treatment was carried out with 5% hydrofluoric acid (PowerEtching 5%, BM4), respecting the 20-second conditioning time for lithium disilicate. Acid was then removed from the ce-ramic surface through abundant water/air spray rins-ing, followed by silane application (Monobond Plus, Ivoclar Vivadent). The enamel was conditioned with 37% phosphoric acid (PowerEtching 37%, BM4), respecting the conditioning time of 30 seconds, and then rinsed with water/air sprays for one minute.

The ceramic was filled with the photocured resin luting cement selected in the trial stage (Variolink Ve-neer Medium) and the veneer was positioned with continuous finger pressure. The excess was removed with a paintbrush and the veneer was photocured for 60 seconds (Bluephase, Ivoclar Vivadent) in the ves-tibular face. Figures 15 through 17 show the result immediately after cementation.

After the porcelain veneers were luted, they were finished with a serrated saw strip on the proximal areas and a #12 scalpel in the cervical region to re-move any excess. Functional adjustments were made. At the next appointment, after complete elimination of excess cement was confirmed, the margins were polished with abrasive silicone (Porcelain Veneer Kit, Shofu Dental; San Marcos, CA) and final photographs were taken (Figs 18a-21).

The patient was asked to perform the phonetic tests again and no problems were observed. The intact ca-nines gave an even more natural appearance to the esthetic rehabilitation without compromising the har-monious smile the patient desired, and she was very happy with the outcome.

Figure 13: The “contact lens” porcelain veneers made with lithium disilicate ceramic positioned in the cast.

Figure 14: The porcelain veneers’ color trial done with try-in paste, showing harmonious colors among natural canines and veneers.

Figure 15: Intraoral photograph of the porcelain veneers immediately after cementation, anterior teeth close-up.

Figure 16: Intraoral photograph of the porcelain veneers immediately after cementation, frontal view in occlusion.

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Figure 17: Intraoral photograph of the porcelain veneers immediately after cementation, occlusal view showing the harmonious position of the anterior teeth after rehabilitation.

Figure 18: Final smile images showing the natural result obtained while preserving the canines: a) frontal, b) right, c) left.

Figure 19: Final facial picture of the patient without (a) and with digital facebow (b): the same alignment was kept, as the canines were not involved in rehabilitation.

a b

Decurcio/Cardoso/de Magalhães/Mederiros

a b c

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Figure 20: Final photograph of the patient showing lighter teeth, as she desired, due to the combination of dental bleaching and porcelain veneers.

Figure 21: Final facial image showing the natural and harmonious result obtained with the “contact lens” porcelain veneers, preserving the natural bleached canines.

The intact canines gave an even more natural appearance to the esthetic rehabilitation without compromising the harmonious smile the patient desired, and she was very happy with the outcome.

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DiscussionPorcelain veneers produce excellent esthetic results with

minimal biological costs. The adhesive technology preserves most of the dental structure, thus contributing to patient satis-faction.15-18 In 1998, Fradeani19 concluded that the only failure found for veneers was in teeth with excessive dentin exposure. For this reason, the authors recommend limiting the prepara-tion to the enamel area (a maximum of 50%, particularly in the marginal level) for a successful result.

The use of composite resin veneers can also be indicated as a well-defined no-preparation technique. However, given the ceramic’s advantages of superior abrasion resistance, high bio-compatibility, and dimensional and chromatic stability over time, the determination was made in this case to use the ce-ramic laminates.20 Furthermore, the indirect technique is pre-ferred when multiple teeth are involved.21

The combined bleaching technique adopts the best charac-teristics of in-office and take-home whitening.22,23 Among the advantages of this technique are a better outcome in a shorter time, reduction of the sensitivity inherent in in-office whiten-ing, lower treatment costs due to fewer office visits, and longer-lasting results.23

In the case presented, the trial stage was indispensable as the canines were preserved with no wear or intervention. The try-in pastes allowed us to select the exact color of the cement to be used in luting, decreasing the chance of a result different from what was expected; in other words, increasing predictability.24 To achieve the best esthetic result, it is necessary to have a wide range of try-in paste colors available in the dental office that complement the cement colors, as the cement plays a major role in the final result of thin porcelain veneers.25

It is important to remember that in the case presented the absence of bleaching could result in wear and conventional preparations could result in dentin exposure on the canines, as the patient desired light teeth. Therefore, previous whitening was mandatory for the veneers’ esthetic success.

After some time (perhaps five or six years), there may be changes in the veneers’ color due to changes in the color of the natural teeth. The darkened color of the natural teeth will reflect through the veneers, making it appear as if the ceramic changed in color. According to Jadad and colleagues,26 patients wearing orthodontic appliances who bleached with 8% hydro-gen peroxide in 10 sessions of 45 minutes each presented color changes similar to a group who bleached after removal of the brackets, showing that the permeability of tooth structure and the penetration capacity of the free radicals generated by hy-drogen peroxide allows polydirectional action, reaching even under the brackets and adhesives of orthodontic appliances. The same logic can be considered for bleaching after cementing veneers, in these particular situations, answering to the patients complaint, the teeth can be bleached in the lingual surface and the free radicals are able to reach the vestibular surface, produc-ing visible color change.8

SummaryPrevious dental whitening can be considered a conservative treat-ment because “contact lens” porcelain veneers can be carried out with minimal or no preparation in naturally darkened teeth.

Acknowledgment

The authors thank laboratory technician Wilmar Porfirio (Goiás, Brazil) for his work on the case discussed in this article.

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Dr. Decurcio owns a practice in Goiás, Brazil.

Dr. de Carevalho Cardoso owns a practice in Goiás, Brazil.

Dr. Rodrigues de Magalhães practices in Goiás, Brazil.

Mr. Medeiros is a photographer in São Paulo, Brazil.

Disclosures: The authors did not report any disclosures.

Observation of the mock-up confirmed that the planned treatment would produce a good esthetic result with preservation of the canines due to the bleaching done previously.

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