Additive Contour of Porceiain Veneers:A Key Eiement in Enamei Preservation,

Adiiesion, and Estiietics for AgingDentition

Pascal MagneVWilliam H. Douglas^

Esthetics and function are equal concerns when restoring the anterior dentition. Modern concepts inrestorative dentistry have brought new solutions through bonded porceiain veneers that are stress distrib-utors and involve the crown of the tooth as a whole in supporting occlusai force and masticatory function.This recovery of the original biomechanics of the intact tooth, the biomimetic principie, is particuiariy vaiu-abie when considering the restoration of an aging dentition. Both function and appearance are affected bythe senescent changes of the aging teeth. Erosion and surface wear iead to a progressive thinning ofenamel, uitimately leading to increased crown flexibiiity and higher surface strains. It appears thereforethat the restoration of tooth volume will not oniy re-establish the originai and youthful appearance of thesmile but wili also allow the biomimetic recovery of the crown. The final treatment outcome strongiy de-pends on the therapeutic approach chosen, the driving force of which should be the preservation of thethin remaining enamel. While a number of preparation techniques wiil expose dentin to a great estent, theprinciple of enamel preservation can stiil be fulfiiied by the use of a specific approach. This articie de-scribes a treatment method which includes the use of a diagnostic tempiate. This type of work strategy,documented with clinical cases, integrates additive wax-ups and acrylic mock-ups. The iatter will provide asignificant amount of diagnostic information and economy of tooth substrate, the importance of whichcannot be overestimated in the completion, functionaiity, and iongevity of the final restoration.J Adhesive Dent 1999; 1:81-92. Suti/n/ttetí for publication: 02.11.98: accepted for publication: 06.12.98.

Numerous clinical studies«.iû.i2.i3.23.26,28.29,33.34

have revealed the good clinical performance of

porcelain laminate veneers ¡PVs). Based on these

promising evaluations and motivated by the princi-

ple of tooth preservation, a new range of indica-

^ Visiting Associate Professor, Minnesota Dental Research Center forBiomaterials and Biomechanics, Departrnent of Oral Science,School of Dentistry, University of Minnesota, Minneapolis, Min-nesota, USA: Lecturer, Department of Prosthodontics and Depart-ment of Prevention and Tnerapeutics. School of Dental Medicine,University of Genera. Switzeriana.

'' Professor and Academic Directcr, Minnesota Dental Research Cen-ter for Biomaterials and Biomechanics, Department of Oral Sci-ence, School of Dentistry, University of Minnesota, Minneapolis,Minnesota, USA.

Reprint requests: Dr Pascal Magne, University of Minnesota, Min-nesota Dental Research Center for Biomaterials and Biomechanics,Department of Oral Science, Schooi of Dentistry, 16-212 Moos Tower,515 Delaware Street S.E., Minneapolis, MN 55455-0329. E-mail:pascaliiSweb.dent.umn.edu

tions for PVs has been defined,"'i^ including cases

of crown-fractured incisors^-^ and worn down ante-

rior dentitions.3s.37 pvs permit, above all, avoidance

of the use of a conventional type of fixed prosthetic

restoration and maintenance of tooth vitality in

spite of a severe breakdown of tooth structure.

Such enhanced appiications of PVs have marked a

turning point in restorative dentistry, generating

considerabie improvements invoiving both the bio-

logical aspect (ie, economy of sound tissues) and

the sooio-economical requirements (ie, decrease of

costs when compared to traditionai and more inva-

sive prosthetic treatments). At the other end of this

spectrum, more cosmetic indications for PVs have

emerged as a result of patients' growing esthetic

expectations (Figs l a and lb). Even though it does

not constitute a primary objective in dental medi-

cine, oral esthetics requires speciai consideration.

Modification of form, position, and color of anterior

teeth generate significant effects on the smile.

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Figs l a and l b Typical case of prematurely aged dentition. Tooth voiume is iost mainly on teeth 11 and 21; the main request ofthe patient is for restoration cf the prominence of these two teeth (la). The left centrai incisor is nohvitai and discolored. Interhalbleaching of the iatter was foiiowed by a customized diagnostic approach (acrylic mock-up) and the completion of two porcelainveneers aiming to recover the original volume of the teeth ( lb]. A rational procedure allowed the preservation of the initial thinenamel (see Figs 7a to 7f, same patient),

Fig 2 Naturally aged dentition. The reduced thickness of enamel is first revealed by the abnormally saturated shade (thin enamelbeing more translucent, and the dentin underneath more perceptible). Numerous crack lines stahd as a possible oonsequence otthe cyclic strains experienced by the thihned enamel over the years.

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which in turn contributes to the personality and thefunctional social life of the patient. Balanced ante-rior tooth prominence is a strategic element of thesmile, which can be iost during aging, thus generat-ing new chailenges for the restorative dentist.^'^Both enamel surface wear and color changes canbe responsible for this degenerative phenomenon.The great interest in vitai bleaching is just one ex-ample of the driving force to rejuvenate tooth ap-pearance, which has given esthetic dentistry animportant place in the range of dentai services of-fered to the public.

BIOMIMETIC INTEGRATION OF PORCELAINVENEERS

The color and cosmetic problems related to toothaging, however, should not be the oniy concerns ofthe restorative dentist,^ it may be argued that therecovery of the original biomechanics of the intactcrown, the biomimetic principie, is an important cri-terion of successfui restorative dentistry. The in-creased crown flexibiiity following loss of palato-labial dimension in worn teeth can be associatedwith functional and mechanicai problems. It wasdemonstrated that a sufficient and uniform thick-ness of enamel is essential to the balance of func-tional stresses in the anterior dentition,22 Thin,aged enamei can generate high strain concentra-tions during function. Surface cracks typically foundon aged teeth are the consequence of this problem(Fig 2), Enamel thickness recovery therefore can beregarded as a combined esthetic and biomechani-cal endeavor. Composite resins have not provenable to replace enamel and restore the originaitooth stiffness,30 In a recent in vitro investigation,PVs were shown to effect a "biomimetic" recoveryof the tooth mechanics, even when bonded to ex-tensive dentin surfaces,i^ On the other hand, com-posite resin veneers often present signs of earlyfatiguéis (chipping-type fractures), marginai mi-croieakage,!'' and poor acceptance by the patientsin comparison to PVs,^^ Freehand applioation ofcomposite resins, however, remains particularlyuseful in the young patient as interim restorationsprior to the final PVs, In specific cases where theentire smile line of the patient is involved, the diffi-culty of simultaneously mastering general form andlength of the teeth involved must be added to theshortcomings of direct composites mentionedabove. Consequently, PVs may be proposed as

yielding a more predictable result, providing thatthe moderate sacrifice of sound tooth structure andthe costs invoived in the technique are expiained toand accepted by the patient.

DEVELOPMENT OF RATIONAL DIAGNOSTICTOOLS AND PROCEDURES FOR PORCELAINVENEERS

In most cases of esthetic rehabiiitation, the treat-ment objective must be reached with the help of adiagnostic tool,20 The latter can consist of a two-step approach: first, the development of a diagnos-tic wax-up and, second, the fabr icat ion of acorresponding template to be evaluated in vivo bythe patient. In the case of PVs, a customized ap-proach had to be developed. The aim ofthe presentarticle is to present simpie but essential tools: theadditive diagnostic wax-up and the acrylic mock-up,the use of which is indicated during diagnosticsteps and tooth preparation procedures for the opti-ma! restoration of the aging dentition using PVs.Two eiements must be emphasized: (1) the objectiv-ity and the simplicity of the approach and (2j thesignificant amount of diagnostic information andpreservation of tooth substrate invaluable to thecompletion, function, and longevity of the finalrestoration.

ADDITIVE DIAGNOSTIC WAX-UP: INSTRUMENTFOR ENAMEL PRESERVATION

Gênerai Considerations

Enamei constitutes perhaps the most highly spe-cialized tissue in the body. It has been extremelyvaluable to the ciinician since 1955, when Buono-core showed it to be an essential substrate forbonding.6 Today, the value of enamel bonding is wit-nessed by the predictable iong-term clinical suc-cess of PVs,i' 2s.3' Enamel is a brittie structure, theintegrity of which is dependent on the crack-arrest-ing effect of the thick, longitudinally oriented coiia-gen fibers of the dentin-enamei junction^^ (DEJ),Therefore, the optimal preservation of both enameland the DEJ must be consciousiy promoted by theappropriate tooth preparation technique.

When the initial enamel is thin, as is the casewith aged or worn incisors, preparation methodsusing the preexisting tooth surface as a reference

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for enamel reduction are absolutely contraindi-oated. So is the "simplified laminate preparation"associated with specific cutting tools to avoid free-hand preparation.il In the proposed procedure, auniform tooth reduction of at least 0,5 mm is real-ized using diamond burs with calibrated rings. An-other classical preparation method, using thepreexisting tooth surface as a guide, consists intaking silicon indices of the labial surface of the un-prepared tooth. Significant dentin exposures are ex-pected using such a freehand procedure on intactcentral incisors as demonstrated by Nattress etal.2^ The situation is most critical when treatingaging dentitions with thin initial enamel; it can beanticipated that the use of the above-mentionedtooth reduction methods may lead to extensive ex-posure of dentin.

Accordingly, a first and key element for enamelpreservation during tooth preparation is the defini-tion of the final tooth volume. Specifically, when asignificant thickness of enamel is initially missingbecause of a history of wear or erosion, the futurerestoration should aim to recover the original vol-ume of the tooth. This, as noted above, will thenrestore an adeduate tooth prominence and bio-mimetic behavior of the crown. ^ Above all, it willallow significant preservation of enamel substrateand the supporting DEJ during tooth preparation.Therefore, a silioon index of an additive wax-up con-stitutes the essential tool used as a reference fortooth reduction (see details in seotion on "Predict-abie tooth preparation").

Essentials for the Additive Wax-up

In this first stage of the diagnostic approach, intu-ition, sensitivity, and a good perception of the pa-tient's individual character should allow the dentaltechnician to define a preliminary prosthetic goal.As previously described, for the aging dentition, thisis mostly obtained by the application of wax to thepreliminary model. This procedure requires preciseknowledge of the critical elements of tooth ana-tomy. An essential learning step results from thesystematic observation of natural teeth. The use ofstone replicas covered by metallic contrast powderis very useful in comprehending the anatomy of theintact facial tooth surface (Fig 3). The iandmarks ofdifferent basic shapes are defined by the verticalproximal crests. They represent fundamental transi-tion lines between the facial and proximal surfaces.

Because of their prominence, these ridges are thefirst element to wear off and therefore are the firstelement that should be recovered by the addition ofwax to the preliminary model (Figs 4c and 4d), Theposition and arrangement of these lobes will be adeterminant for the definition of tooth form. A sec-ondary step of the wax-up procedure consists inrecreating the superficial vertical lobes and hori-zontal developmental lines that define the sec-ondary and tertiary enamel surface topography.

ACRYLIC MOCK-UP: INSTRUMENT FOR DIAGNO-SIS AND PREDICTABILITY

A predictable outcome ofthe treatment is essentialwhen planning an important esthetic rehabilita-tion.^° The basis of the prescribed treatment is de-termined by the diagnostic analysis. Nevertheless,the latter should remain a simple and rational pro-cedure. If subtle changes are being considered, it isadvisable to communicate these to the patientusing mostly visual devices in order to avoid eventhe slightest misunderstanding.

At this stage of the diagnostic approach, the ad-ditive tooth volume must be approved by the pa-tient, resulting in total agreement on the definitionof tooth shape, size, and length. In traditionalprosthodontics (full orown coverage), preliminarytooth preparation usually precedes the completionof the diagnostic template which is represented bythe temporary restoration itself.i^'^o,31,32 sucintreatment planning is not possible with PVs, Be-cause of the reduced thickness of the laminate andthe intrinsically conservative approach, the final vol-ume of the restoration plays a decisive role in thedetermination of the tooth preparation itself. The invivo evaluation and full approval of the template bythe patient should, therefore, precede tooth prepa-ration procedures.

The simplest method consists of fabricating anacrylic template directly in the patient's mouth oronto an intact study cast using self-curing resinmolded on the unprepared tooth surfaces with a sil-icon matrix of the wax-up (Figs 4a to 4k). Subsequently, the patient him- or herself can easilyexamine this removable mask. A oommon situatiormust be pointed out: when looking at the templatefor the first time, the patient will usually oomplairabout the excessive tooth volume. This reaction ÍÍnormal and understandable, since the process o-wear and erosion is slow and extends over years

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Fig 3 intact teeth, detaiis of the faciai morphoiogy. These stone replicas were coated with a metaiiic contrast powdei to highiigiiianatomic and surface texture characteristics. The proximai crests are very prominent, specificaiiy on the mesial aspect.

Figs 4a to 4k Diagnostic procedures. This South American patient presents an open gold crown on the right lateral incisor and anold resin crown on the left central incisor (4a¡, After removal of the latter, a preliminary impression was taken (4b¡, followed by therealization of a direct temporary acrylic on tooth 21 (remcvai of the open crown did not require temporization). Two porcelain ve-neers were planned for teeth 11 and 12, and a porcelain-fused-to-metai for tooth 21, The detail of the initial situation reveáis theloss of enamei on the right central incisor (4c). The new volume of the tooth was carefuliy designed bythe wax-up including super-ficial lobes and proximal ridges |4d). The final treatment objective is first defined on the model |4e), then tested in vivo by the fab-rication of a mock-up: a siiicon index of the wax-up is filled with liquid resin (4f) and pressed on unprepared teeth, A thick iayer ofVaseline must be previously appiied to the teeth to avoid adhesion between the acrylic mock-up and eventual preexisting resihrestorations (4g), The siiicon matrix is maintained in position untii complete curing of the resin (the mcck-up is usuaiiy thin andwould be deformed by premature removai), the operatory field being cooled with abundant rinsing (4h), The resin tempiate can beeasily unlocked and removed by inserting a sealer at the proximal surface (4i], The final acrylic moch-up is left to the patient forprolonged trial of several days (4j) and eventually bonded by enamel spot etching. Based on the patient's accurate input at theend of the trial, minor modifications can be integrated to the final restorations (4k), Details of tooth preparation procedures arepresented in Figs 8a to 8f,

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Figs 4a to 4k continued.

Small changes in tooth length and shape take piaceprogressively, without generating sudden modifica-tion in the patient's smiie. This long degenerativeprocess, however, is now oounteracted by an in-stant restorative procedure (the moci<-up itseif) in-

voiving major changes in the smile design. The pa-tient must therefore be prepared and informed; anobjective esthetic evaluation requires a prolongedclinical trial of several days. Accordingly, the un-changed mocl<-up is left to the patient for assess-

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Figs 5a to 5c Typical evaluation of a mock-up. Note the large preexisting Class IV composite restorations on the central ihcisors ofthis young female. Despite the harmonious relationship between the lower lip and the incisai line, the patient, who did not requestlonger teeth, did not initially approve the acrylic mock-up (5b). After several days of trial, the patient felt comfortable and gave totalconsent for the fabrication of the corresponding final veneers (5c¡.

ment for one week. The template can be tempo- method is not time consuming, modifications oftherarily bonded by enamel spot etching if necessary.At the next appointment, the patient often feelsmore comfortable and discusses eventuai changeswith more objectivity (Figs 5a to 5c). Since the

initial diagnostic study can be carried out and inte-grated into a new tempiate. The actuai tooth prepa-rations wiii only be performed after the patient'sformai approval.

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In certain circumstances where the original toothvolume must be reduced or transposed (eg, correc-tion of tooth position), the previousiy described ap-proach is ciearly not applicabie. Such exceptionaisituations wiil require preiiminary tooth prepara-tions which create minimum space for the compie-tion of the mock-up that will also act as a temporaryrestoration. After the patient approves the configu-ration ofthe latter, tooth preparations are finalized,A similar sequence can be applied with extremeiydemanding patients. These individuáis often dem-onstrate a great deficit of self-confidence and seemimmediateiy confused by the insufficient estheticquality of the traditionai mock-up. They are unableto objectively evaluate the template unless more es-thetic stratified acryiics are used. Here, preiiminarytooth preparations and impressions are best indi-cated for the laboratory fabrication of an elaboratetemplate using, for instance, a sandwich tech-

Such diagnostic commitment may seem exagger-ated. It proves, however, to provide the treatmentoutcome with maximum predictabiiity, resuiting in ahigh probabiiity of recovering the patients' confi-dence. This aspect of the reiationship is invaluablewhen compared to the possibie consequences ofinadequate treatment objectives.

PREDICTABLE TOOTH PREPARATION:TECHNIQUE AND BONDING

When the approach described above is strictly ap-plied, practical restorative procedures can be con-sidered to possess maximum safety and pre-dictability. This Is particularly important when theoperator is confronted with the rehabilitation of theaged dentition. The final objective being well de-fined, the active therapeutic effort can now focuson the technical procedures for tooth preparation.

The simplest and most important tools forenamel reduction are represented by sectioned sili-con indices from the wax-up, in order to obtain astiff and accurate matrix, the model can be sub-jected to a pressure of 4 atmospheres (using apressure pot) during the setting of the siiicon mater-ial. The index can be cut in two, and the facial haifprepared according to a "notebook method" (Figs6a and 6b), The latter is like a bound multi-layerindex that wiil allow efficient checking of the hardtissue reduction st different horizontai levels ofthepreparation. Before starting to reduce enamel, the

placement of the facial index reveals that someareas of the tooth surfaoe (typically the proximalcrests and transition lines) wiil require minimumpreparation (Fig 7a), The axial reduction does notrequire the use of specialized rotary tools but onlytapered round-ended burs classically designed fortraditional fixed prosthodontics. Three different di-ameters of burs are recommended (eg, 856L-014,S56L-016 and 856L-020, Brasseler, Savannah, GAor D6, 235 and 237, Intensiv, Viganello, Switzer-land), the thinnest bur being used first for cuttingproximal reduction grooves, then the medium burfor faciai reduction grooves. The depth of eachgroove is individually controlled using the siliconguide (Figs 7b and 7c), The preexisting surface ofthe tooth must be ignored, using only the surface ofthe siiicon index to check the depth of the cuts. Thegross axiai reduction is preferably carried out with alarger bur to prevent re-penetration into the grooves(Fig 7d), In this simple way, wavy surfaces can beavoided, A uniform space of 0.5 to 0,7 mm shouldbe generated by this method (Fig 7e), uitimateiyproducing the same thickness of ceramic at theproximal and axial levels. The palatal half of the sili-con index is finally used to check the incisai clear-ance (1,5 mm is required), followed by thecompletion of the palatal finish line, which usuallyconstitutes the last step of the tooth preparation[Fig 7f). It is essentiai to produce preparations with-out sharp angles, considering that the improvedquality of both the preparations (sufficient ciear-ance for the ceramic, smooth contours, absence ofundercut) and the finai impressions will significantlyfacilitate the work of the dental ceramist, leading tca minimal use of die spacer, thus reducing the riskof post-bonding cracks.3.i -2i

Despite a major effort to confine the preparationwithin the enamei shell, old preexisting Class III andiV restorations may lead to more extensive cover-age and involve deeper preparations into the dentin(Figs 8a to 8f), Accordingiy, local application of adentin bonding agent (DBA) is recommended. Theapplication of the DBA is usually delayed until thelast treatment stage, just before iuting the veneer,A new approach has been recently proposed to opti-mize the DBA appiication,5.IS,27 Because freshiyprepared dentin appears to have a much superiorpotential for adhesion when compared to contami-nated dentin, the DBA is best applied immediatelyafter the compietion of tooth preparation and be-fore the finai impression (Figs 8d and 8e), Addition-aiiy, this immediate appiication of the DBA and

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Figs 6a and 6b The "notebook method" for the preparation of the silicon index. The traditional silicon indes was cured under 4atm in a pressure pot, then sectioned horizontally. The different layers are still bound on one side the index (6a). The matrix canbe opened like a book to visuaiize the entire aspect of the reduction, from incisai to the most cervical part (6b).

Figs 7a to 7f Rational tooth preparation procedure (same patient presented in Figs l a and lb¡ . The initial control with the siliconindex shows aiready available space for the future restoration (7a). Depth cuts are barely visible because of the minimum sacrificeof sound tissues (7b). Each groove is individually controiied with the silicon matrix. Some aspects of the preexisting surface will bealmost untouched, eg, the faciai-proximai transition line angles at the distai surface of tooth 11 (7c), A retraction cord is placed,followed by axial reduction: a larger bur is used (le, 856L-020, Brasseier) to prevent the formation of wavy surfaces resuiting fromre-penetration into the deptn cuts (7d). The controi of axiai reduction reveals that minimum reduction was made at the ievel ofproximal crests, leading to a maximum preservation of enamei (7e). The incisai edge reduction is followed by the definition of thepalatai finish line (le, a slightly concave, butt margin) using a large round diamond bur (ie, 801-016 or 801-023, Brasseler)(7f),

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Figs 8a to 8f Tooth preparation procedures in the presence of iarge preexisting Ciass III restorations [same patient presented inFigs 4a to 4((), An open gold crown was originally removed from tooth 12 and the interdental surfaces were separated up to thepalatal margin of the class ili restorations (8a), The placement of the silicon index shows that the facial wear was iimited by thepresence of the goid crown on tooth 12 whiie no depth cut wiii be necessary on the central incisor due to the significant spacegenerated by the additive wax-up (8b, see aiso corresponding situation in Figs 4c and 4d), As a result, a maximum amount ofenamel could be saved on the facial aspect of the central incisor (Fig 8c|, Significant dentin exposures, however, are generatedproximaiiy and necessitate immediate lining with a dehtin bonding agent, including dentin etching (Bd), The use of a filled resin(Optibond FL, Kerr, Orange, CA) allows an accurate placement of the adhesive prior to impression taking (8e), To promote adhe-sion of the iuting composite to the preexisting adhesive resin, surface roughening of the iatter (ie, using a coarse diamond bur atiow speed] and alcohol drying were performed just before luting the finai veneer (8f).

sealing of dentin will prevent bacterial leakage andsensitivity during provisionalization and provide thepulpo-dentinal organ with maximum protection.With this technique, further adhesion of the lutingagent to the preexisting dentin adhesive must bepromoted by surface roughening and drying with al-cohol just before luting procedures, ^

CONCLUSION

A well-defined work strategy for the porcelain ve-neer reconstruction is presented, documented byclinical cases. In most cases of esthetic rehabilita-tion, the treatment objective must be reached bymeans of a significant diagnostic effort. The pres-ent article has shown that this can be achieved bysimple but essential tools: the additive diagnosticwax-up and the acrylic mock-up, which achieve opti-mal contours and patient accommodation and ap-

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proval. The transfer of vital biological information tothe tooth preparation stage can be carried out by aleafed silicon index, the so-called "notebook" tech-nique. Each stage ofthe procedure is characterizedby objectivity and clinical controi. This assures theretention of a maximum amount of enamel whichlies at the heart of the porcelain veneer approach,it is strongly suggested that the advantages of PVsgo beyond esthetics to proffer complete biomechan-ical recovery of anterior function, the so-calledbiomimetic principle. This is expressed in the labio-palatal resistance of PVs to anteroposterior move-ment as in food incision and anterior guidance. It isprobably safe to say that with the continual im-provement of materials and diagnostic techniques,there is potential for enhanced application of PVs tocases where greater loss of hard tissue has oc-curred.

ACKNOWLEDGMENTS

The authors wish to express their gratitude to Mr Michel Magne(Oral Design Center, Dental Laboratory. Montreux, Switzerland)tor the realization of the technical work presented in this report.The first author was supported by the Swiss Foundation for Med-ical-Biological Grants and in part by the Minnesota Dentai Re-search Center for Biomaterials and Biomechanics.

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92

ORAL HEALTHfor the Orthodontic Patient

Siegward D. Heintze, Paul-Georg Jost-Brinkmann.Christian Finke, Rainer-Reginald Miethke

This book focuses on practical, preventiveoral hygiene measures for the orthodontic

patient. The authors emphasize patient eduoa-tion and motivation, as well as preventivetechniques, with the goal of optimal orthodon-tic results. Also presented is a fundamentalanalysis of the detailed factors involved in thedevelopment and prevention of caries andperiodontitis in the orthodontic patient.

Using this book, the entire dental team candevelop individualized preventive programs forpatients with orthodontic appliances.

160 pp (so/tcover),¡ 70 illus (most in color);ISBN O-S6715-295-8;US$53

Oral Healthfor the

Orthodontic Patient

Chapter I Effects of Orthodontic Treatmenton Oral Health

Chapter 2 Evaluation of Oral Health andMeasurement of Risk

Chapter 3 Professional Measures forReducing Oral Bacteria

Chapter 4 Home-Care Measures forReducing Oral Bacteria

Chapter 5 Pharmaceutical Adjuvants forPreventing Caries and PeriodontaiDisease

Chapter 6 Systematic Program for PreventingCaries and Periodontai Disease inOrthodontic Patients

To ORDER

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